HOSPITALS: 


HISTORY,  ORGANIZATIOJ(,  AND  COXSTRUCTIOX, 


BOTLSTOX  PKEE-ESSAY  OF  HARVARD  UXIYERSITY  FOR  1876. 


W.  GILL  WYLIE,  M.D. 


"an  o^^■CE  OF  peetentiox   is  woetii  a  pound  of  cube." 


KEW   YORK: 
D.    APPLETON    AND    COMPANY, 

549  &  551  BROADWAY. 
1877. 


BOYLSTON  MEDICAL  PRIZE  QUESTIONS. 


The  Botlston  Medical  Committee,  appointed  by  the  President  and  Fellows  of 
Harvard  University,  consists  of  the  following  physicians : 

J.  B.  S.  Jackson,  M.  D.,  Henry  J.  Bigelotv,  M.  D., 

D.  H.  Stoker,  M.  D.,  Richard  M.  Hodges,  M.  D., 

Morrill  Wyman,  M.  D.,  Calvin  Ellis,  M.  D. 

Samuel  Cabot,  M.  D. 

At  the  annual  meeting,  held  June  7,  18  75,  it  was  voted  that  no  dissertation 
worthy  of  a  prize  had  been  offered  on  either  of  the  subjects  proposed  for  1875. 

The  following  are  the  questions  proposed  for  1876: 

1.  Civil  Hospital  Construction  (not  of  Lunatic  Asylums) ;  Location,  Materials, 
Arrangement,  Warming,  Ventilation,  Drainage,  Lighting ;  with  Designs. 

The  author  of  a  dissertation  on  this  subject,  considered  worthy  of  a  prize,  will  be 
entitled  to  a  premium  of  Three  Hundred  Dollars. 

Dissertations  on  the  above  subjects  must  be  transmitted,  postpaid,  to  J.  B.  S. 
Jackson,  M.  D.,  Boston,  on  or  before  the  first  Wednesday  in  Api-il,  1876. 

Each  dissertation  must  be  accompanied  by  a  sealed  packet  on  which  shall  be 
written  some  device  or  sentence,  and  within  which  shall  be  inclosed  the  author's 
name  and  residence.  The  same  device  or  sentence  is  to  be  written  on  the  disserta- 
tion to  which  the  packet  is  attached. 

The  writer  of  each  dissertation  is  expected  to  transmit  his  communication  to  the 
President  of  the  Committee,  J.  B.  S.  Jackson,  M.  D.,  in  a  distinct  and  plain  hand- 
writing, and  with  the  pages  bound  in  book  form,  within  the  time  specified. 

Any  clew  by  which  the  authorship  of  a  dissertation  is  made  known  to  the  com- 
mittee will  debar  such  dissertation  from  competition. 

Preference  will  be  given  to  dissertations  which  exhibit  original  work. 

All  unsuccessful  dissertations  are  deposited  with  the  Secretary,  from  whom  they 
may  be  obtained,  with  the  sealed  packet  imopened,  if  called  for  within  one  year 
after  they  have  been  received. 

By  an  order  adopted  in  1826,  the  Secretary  was  directed  to  publish  annually  the 
following  votes : 

1.  That  the  Board  do  not  consider  themselves  as  approving  the  doctrines  con- 
tained in  any  of  the  dissertations  to  which  premiums  may  be  adjudged. 

2.  That  in  case  of  publication  of  a  successful  dissertation,  the  author  be  consid- 
ered as  bound  to  print  the  above  vote  in  connection  therewith. 


At  the  annual  meeting,  held  June  5,  1876,  it  was  voted  that  a  prize  of  three  hun- 
dred dollars  be  awarded  to  Dr.  W.  Gill  Wylie,  of  New  York,  for  a  dissertation  on 
"  Civil  Hospital  Construction." 

It  was  also  voted  that  a  dissertation  on  "  Hospital  Construction,"  bearing  the 
motto  "  Mille  mali  species,  mille  salutis  erunt,"  was  of  such  a  high  order  of  merit 
that  the  committee  recommend  its  publication  by  the  author. 

Richard  M.  Hodges,  M.  D.,  Secretary, 
Boston,  Mass. 


CoPYKiGHT  ET  D.  APPLETON  A^'D  COMPANY,  1S77. 


lOO 


PKEFACE. 


As  tliere  may  be  persons  who  consider  the  subject 
of  this  essay,  especially  the  chapter  on  "  Construction," 
somewhat  outside  the  field  of  a  practising  physician's 
work,  perhaps  a  few  words  in  regard  to  the  circum- 
stances which  led  to  the  Avriting  of  it  may  not  be  out 
of  j^lace. 

More  than  five  years  ago,  while  a  surgeon  on  the 
Kesident  House-Staff  of  Bellevue  Hosj)ital,  a  large 
pauper-hospital  of  this  city,  I  had  an  excellent  oppor- 
tunity for  seeing  the  bad  effects  of  poor  nursing  and 
defective  construction  on  the  welfare  of  patients.  At 
that  time,  with  rare  exceptions,  the  nurses  were  igno- 
rant and  in  some  cases  worthless  characters,  who  ac- 
cepted the  almost  impossible  task  of  attending  to  and 
nursing  from  twenty  to  thirty  patients  each.  There 
were  no  night-nurses ;  the  night-watchmen — three  in 
number  to  a  hospital  of  eight  hundred  beds — were  ex- 
pected to  give  assistance  to  patients  requiring  attention 


4  PREFACE. 

during  the  niglit.  Tlie  liosj)ital-buildmg,  originally  an 
old  prison  and  almshouse  erected  sixty  years  ago,  had 
been  added  to,  and  was  now  a  massive  stone  structure, 
with  three  stories  and  a  basement.  The  wards  were 
only  separated  from  each  other  by  the  intervening  par- 
titions inclosing  the  water-closets  and  bath-rooms,  which 
were  without  ventilation,  except  as  they  opened  into  the 
wards.  In  some  instances  there  were  only  six  windows 
to  wards  of  twenty  beds. 

The  sanitary  condition  of  the  hosj)ital  was  shocking, 
notwithstanding  the  fact  that  to  the  visitor  the  wards 
presented  a  clean  and  orderly  appearance.  I  saw,  while 
on  duty  in  the  wards,  patients  die  from  septic  diseases 
contracted  in  the  wards  after  the  slightest  surgical 
operations  or  injuries.  From  forty  to  sixty  per  cent, 
of  all  amputations  of  limbs  proved  fatal ;  and  I  saw  a 
strong,  healthy  man  die  from  pyaemia  following  an  am- 
putation of  a  great-toe. 

From  the  twelfth  official  annual  report  of  the  hos- 
pital I  take  the  following : 

January  1,  1872. 

Number  of  patients  remaining  in  liosj^ital 779 

"         "  admissions  during  the  year  1871 6,859 

"        "  births  "         "       "    1871 376 

Total  number  of  patients  "         "       "     1871 7,514 

Number  of  deaths  "         «       "    1871 1,102 

Which  gives  1  in  every  C.8,  or  14.7  deaths  in  every  100. 
In  a  total  of  1,102  deaths  we  find — 


PREFACE. 


30  cases  are  recorded  as  caused  by  pyaemia. 


1 

case 

is 

1 

1 

1 

1 

1 

33 

cases  are 

pyaemia  and  delirium  tremens. 

"         "   pneumonia. 

"         "   necrosis  of  sternum. 

"         "   morbus  coxarius. 

"  "  tertiary  syphilis. 

"         "  resection  of  elbow, 
puerperal  peritonitis. 


From  tlie  above  we  get  in  1,102  deaths  69  caused 
by  hospital-poisons,  or  1  in  every  15.95,  or  G.02  in 
every  100. 

Takiug  the  number  of  births  as  representing  the 
number  of  women  delivered  during  the  year:  In  376 
confinements,  33  died  of  puerperal  fever,  or  1  in  every 
11.30;  or  8.7  in  every  100  of  all  the  women  confined 
died  of  puerperal  fever.  Since  the  introduction  of 
trained  nurses,  the  removal  of  the  lying-in  patients, 
the  reduction  of  the  number  of  beds  from  eight  to 
six  hundred,  and  the  use  of  Lister's  antiseptic  dress- 
ings, the  condition  of  the  hospital  has  baen  very  much 
improved,  but  the  faults  of  the  buildings  remain  the 
same. 

Becoming,  in  the  spring  of  1872,  a  member  of  the 
standing  Committee  on  Hospitals  of  the  New  York 
State  Charities  Aid  Association,  I  devoted  my  sj^tare 
time  to  studying  the  subjects  of  trained  nursing  and 
of  hospital-construction,  spending  a  summer  abroad  for 
the  purpose. 

A  paper  read  by  me  before  the  Association,  Decem- 
ber, 1873.  gave  substantially  the  same  2:>lan  for  a  model 


6  PREFACE. 

ward  wliicli  is  described  in  this  essay.  The  Association 
requested  the  publication  of  the  paper,  but  I  felt  that 
the  subject  required  more  study.  In  February,  1876, 
the  chapter  on  "  History  of  the  Origin  and  Develoj^- 
ment  of  Hospitals :  their  Progress  during  the  Century 
of  the  American  Republic,"  was  read  before  the  New 
York  Academy  of  Medicine,  after  which,  deciding  to 
compete  for  the  Boylston  Prize,  I  wrote  hurriedly,  dur- 
ing March,  the  rest  of  the  essay,  and  forwarded  it  to 
Cambridge,  in  accordance  with  the  conditions,  3d  of 
Aj)ril,  1876.  Since  then  I  have  withheld  it  from  the 
press,  in  hopes  of  gaining  time  to  rewrite  it,  but  profes- 
sional engagements  have  prevented  a  full  revision. 

I  do  not  present  this  book  as  a  complete  work  on 
hospitals.  For  the  best  statement  of  all  the  details  of 
internal  management,  I  refer  my  readers  to  the  "  Hand- 
book for  Hospital  Visitors,"  Document  No.  13,  of  the 

State  Charities  Aid  Association. 

W.  G.  W. 

New  York,  ]\Tarc7i  1,  1877. 


ooi^te:nts. 


CHAPTER  I. 

PAGE 

History  of  the  Origin  and  Development  of  Hospitals  :   their  Progress 

DURING    THE     CeNTPRY   OF    THE    AMERICAN    REPUBLIC. — CONCLUSION    AS    TO 

THEIR  Origin    .        .  .  .  .  .  .  .  .9 

CHAPTER   II. 

Relations  of  Hospitals  to  Pauperism. 

Necessity  for  Hospitals. — Increase  and  Cost  of  Charities. — Education  to  replace 
Alms. — Personal  Relations  to  Charity.— Objections  to  Hospitals. — Pro- 
posed Plan  for  governing  Charity      .  .  .  .  .  .56 

CHAPTER  III. 
Organization  and  Management. 
Boards  of  Managers  and  Medical  Boards. — Value  of  Hospital  Appointments. — 

Influence  of  Women  in  Hospitals. — The  Superintendent      .  .  .68 

CHAPTER  IV. 
The  Construction  of  a  Civil  Hospital. 
Excuses  for  Faults  of  Construction. — Location. — Preparation  of  the  Grounds. — 
Character  of  the  Buildings. — Classification  of  the  Patients  according  to 
their  Diseases. — The  Ward  ;  Comparative  Costs  of  Construction. — Shall 
the  Buildings  be  permanent  or  temporary  in  Character  ? — Disease-Germs 
and  Disinfectants. — Character  of  the  Ward.— Number  of  Beds  to  Each 
Ward. — Cubic  Air-Space  to  Each  Bed. — Shape  and  Size  of  Ward. — Posi- 
tion of  the  Ward  in  Relation  to  Points  of  the  Compass. — Position  of  the 
Service-Rooms. — Connection  of  Service-Rooms  with  the  Ward. — Founda- 
tion of  the  Ward. — Objections  to  Basements  and  Cellars. — Material  for  the 
Walls  of  the  Ward. — Permeable  or  Impermeable  Walls  ? — The  Floors  of 
the  Ward.— The  Windows.— The  Doors  and  Roof.— The  Piazza.— 77ie  Ser- 
vice-JRoom  B uil din ff.—BimensioTis. — Basement. — Wash-Room  and  Water- 
Closets. — Bath-Room. — Day  and  Dining  Room. — Nurse's  Room  and  Linen- 
Shelves. — Reception  and  Examining  Room. —  The  Main  Corridor  .       86 


8  CONTENTS. 

CHAPTER  V. 
Warming  and  Ventilation. 

PAGE 

Different  Methods  of  Ventilation. — Aspiration  versus  Propulsion. — Different 
Methods  of  Warming. — Ward  Heating  and  Ventilation. — Proposed  Method 
of  Warming. — Proposed  Method  of  Ventilation. — Foul-Air  Escapes. — 
Lighting  the  Ward. — Ward-Furniture. — Heating  and  ventilating  the  Ser- 
vice-Room Building  .  .  .  .  .  .  .117 

CHAPTER  VI. 

Pay-Patients  in  Charitable  Institutions. 

Provident  Dispensaries. — Pay- Wards     ......     133 

CHAPTER   VII. 
Special  Isolated  Huts  for  Certain  Important  Cases,  such  as  Ovariotomy  and  others 
extremely  sensitive  to  Infectious  Matter. — The  Plan  of  the  Hut. — Position. 
— Dimensions. — Floor. — Height  from  Ground. — Walls. — Roof. — Windows. 
Door. — Warming. — Lighting. — Ventilation. — Furniture     .  .  .138 

CHAPTER  VIII. 

Administrative  Buildings  and  Arrangement  of  the  Buildings  on  the  Grounds. — 
Separation  of  the  Ward-Pavilions. — Position  of  the  Ward-Pavilions. — Ad- 
ministrative Building. — Bath-House. — The  Apothecary-Shop. — Operating- 
Theatre. — Accident-Ward. — Stable. — Autopsy  and  Pathological  Building. 
— Out-Door  Dispensary. — Laundry. — Water-Supply. — Sewers  and  Drain- 
age.— Cultivation  of  the  Grounds   ......     148 

CHAPTER  IX. 

Relations  of  the  Medical  School  and  the  Training-School  for  Nurses  to  the  Hos- 
pital.— Professors  and  Students. — Reception-Hospitals. — Organization  of 
the  Training-School  .  .  .  .  .  .  .157 

CHAPTER  X. 

Improvement  of  Hospitals  now  in  Use. — Small  Hospitals. — Lying-in  Hospitals. 

— Hospitals  for  Convalescents. — Army-Hospitals. — Insane  Asylums  .     165 

CHAPTER  XI. 

Hospital  Buildings  now  in  Use. 
The  Old  Conglomerate. — Extemporized  and  Irregular  Hospitals. — The  Old  Block 
Plan.— The  Corridor  Plan.— The  Pavilion  Plan.— The  One-Story-Pavilion 
Plan. — Hospitals  of  America,  England,  France,  Germany,  Italy,  and  Spain, 
with  Plans  and  Descriptions  .  .  .  .  .  .182 

Appendix  .........     221 


HOSPITALS. 


CHAPTEK    I. 

HISTOEY  OF  TIIE  OEIGIX  AXD  DEVELOP:\rEXT  OF  HOS- 
PITALS :  THEIR  PROGEESS  DUEES'G  THE  CEXTUEY  OF 
THE   AilEEICAX   REPUBLIC. 

It  is  tlie  common  belief  that  hospitals,  for  tlie  treat- 
ment of  tlie  sick  poor,  are  the  offspring  of  Christianity ; 
that,  previous  to  the  Christian  era,  no  such  institutions 
as  our  hospitals  ever  existed.  The  best  encycloj^aedias, 
both  English  and  American,  make  no  reference  to  the 
fact  that  hospitals  were  known  previous  to  the  coming 
of  Christ,  and  not  infrequently  we  hear  men  in  public 
addresses  making  the  same  mistake.  Beyond  question, 
hospitals  for  the  purpose  of  treating  the  sick  poor  were 
founded  in  India,  among  the  Buddhists,  several  hun- 
dred years  before  the  advent  of  Christ. 

During  the  reign  of  Asoka,  who  died  226  years  b.  c, 
the  Buddhists  cut  on  rocks  their  edicts  on  hospitals, 
one  of  which,  dated  220  b.  c,  can  be  seen  to-day.  It 
directs  that  along  the  routes  of  travel  hospitals  shall 
be  erected,  that  they  be  "  well  provided  with  instru- 
ments and  medicines  consisting  of  mineral  and  vege- 
table   drugs,  with   roots   and   fruits,"    and    also    that 


10  H08PIJALS: 

"  whenever  tliere  '  is  no  provision  of  drugs,  medicines, 
roots,  and  lierbs,  are  to  be  supplied  and  skillful  physi- 
cians are  to  be  aj^pointed  to  administer  tliem,  at  the 
expense  of  the  state." ' 

In  Wise's  "Review  of  the  History  of  Medicine" 
(vol.  i.,  page  392)  there  is  a  quotation  from  Tounour's 
translation  of  the  "  Mahawauso,"  stating  that  "  Buddha 
has  aj)pointed  a  j^hysician  for  every  ten  villages  on  the 
high-road,  and  built  asylums  for  the  crippled,  the  de- 
formed, and  the  destitute.  His  son,  Upatiso,  built  hos- 
pitals for  cripples,  for  pregnant  women,  and  for  the 
blind  and  diseased,  and  Dhatusend  built  hospitals  for 
cripples  and  for  the  sick." 

Scavoneur,  in  his  "Voyages"  (vol.  ii.,  page  489), 
gives  an  account  of  the  Banian  hospital,  which  still 
exists  at  Surat,  at  the  time  of  his  writing,  about  one 
hundred  years  ago : 

"  This  curious  institution  was  supported  by  the  one 
anna  per  cent,  on  the  rupee  of  the  merchant's  clear  gain, 
to  which  were  added  the  fines  of  certain  venal  offenses, 
under  the  supervision  of  the  chief  Banians.  In  1770, 
when  trade  had  decayed,  the  revenue  was  upward  of 
six  hundred  pounds  a  year,  and  so  careful  were  they  of 
the  animals  that  bread-and-milk  was  provided  for  two 
which  could  not  croj)  grass.  The  hos23ital  consisted  of 
twenty-five  acres,  surrounded  with  a  high  wall,  divided 
into  courts  and  defended  by  sheds  and  yards  for  the 
accommodation  of  the  animals." 

Not  far  distant  on  a  rock,  in  Guzerat,  are  the  edicts 
of  Asoka,  cut  on  it  more  than  two  thousand  years  ago. 
Hamilton,  in  his  "Hindostan"  (vol.  i.,  page  718),  tells 
of  an  old  tortoise,  that  w^as  seen  in  one  of  these  hos- 

*  Eeview  of  the  History  of  Medicine,  by  Thomas  A.  Wise,  London,  1867. 


TEEIR  OBIGIF  AND  DEVELOPMENT.  11 

pitals,  that  had  been  there  for  seventy-five  years.  There 
are,  more  or  less,  in  all  Buddhist  countries,  hospitals  for 
incurables,  lepers,  and  such  as  are  afflicted  with  elephan- 
tiasis. 

"  In  the  city  of  Bangkok  there  is,  in  addition  to 
these,  a  hospital  for  poor  lying-in  women ;  and  all  the 
male  and  female  physicians  attached  to  the  court  are 
obliged  to  give  their  services  gratuitously  to  each  one 
of  these  establishments. 

"According  to  the  'Shah  Nameh,'  a  collection  of 
heroic  poems  on  the  ancient  histories  of  Persia,  the  fire- 
worshij)er3  from  the  earliest  times  were  obliged  by 
their  laws  to  provide  suitable  houses  for  the  suffering 
poor  of  their  community,  and  the  king  to  furnish  the 
best  medical  treatment  for  the  inmates  free  of  all  cost. 
In  Bombay  the  noble  hospital  connected  with  Grant's 
College  is  the  princely  gift,  to  the  sick  poor,  of  the  well- 
known  fire-worshiper  and  Parsee  knight.  Sir  Jamsetja 
Jejeeboy.  In  1869  his  wife  and  children  erected  a 
very  magnificent  hospital  for  incurables  near  it.  In  the 
same  year  an  ophthalmic  hospital  was  oj)ened  by  an- 
other munificent  fire- worshiper,  Mr.  Cowlesjee  Jehhaug- 
heer." ' 

It  is  said  that  the  sick  were  treated  in  the  temples 
of  ^sculapius,  1134  years  b.  c,  at  Titanus,  a  city  of 
Peloponnesus,  but  there  is  no  evidence  that  these  tem- 
ples were  used  for  the  purpose  of  treating  the  siclr  poor ; 
still  they  were  in  some  respects  similar  to  our  hosj^itals. 

Dr.  John  Watson,  in  his  "Anniversary  Discourse 
before  the  New  York  Academy  of  Medicine,"  says: 
"  As  asylums,  these  temples  bore  no  inapt  resemblance 

*  Information  from  Mrs,  Leon  Owens,  who  for  many  years  was  a  resi- 
dent of  India. 


12  HOSPITALS: 

to  tlie  liosjiitals  and  infirmaries  of  modern  times ;  into 
which,  in  fact,  some  of  tliem  were  ultimately  converted. 
The  temples  of  JEsculapius,  Cos,  and  Tricca,  according 
to  Strabo,  were  always  filled  with  patients,  and  along 
their  walls  the  tablets  were  suspended,  upon  which 
were  recorded  the  history  and  treatment  of  the  indi- 
vidual cases  of  disease." 

The  valetudinariums  of  the  Komans,  referred  to  by 
Seneca  and  other  writers,  and  which  are  defined  by  An- 
drews, Ainsworth,  Cooper,  and  other  authorities,  as 
places  where  men  lie  being  sick,  sick  men's  lodgings, 
infirmaries,  or  hospitals  for  sick  folk,  a  sick-room,  must 
have  been  institutions  somewhat  similar  to  hospitals. 
As  they  are  not  described  by  any  of  the  many  Roman 
historians  as  public  institutions,  they  were  ^^robably 
something  like  our  private  hospitals — water-cures. 

There  was  a  public  building  on  an  island  of  the 
Tiber  at  Rome  to  which  slaves  were  removed  when 
sick,  and  one  at  Delos  used  as  an  asylum  for  aged 
women,  and  near  some  of  the  temples  houses  were 
erected  for  those  sick  while  visiting  them. 

In  the  East  caravansaries  or  resting-places  for  trav- 
elers have  existed  from  time  imi5iemorial.  In  all  of  the 
early  pilgrimages  some  such  resting-places  were  cus- 
tomary, and  were  usually  found  near  the  shrines  and 
temples. 

After  the  birth  of  Christ,  when  his  words  began  to 
reach  the  hearts  of  men  and  lead  them  to  acts  of  kind- 
ness, and  when  Jerusalem  and  the  roads  a23proaching 
it  were  crowded  with  pilgrims,  sjDecial  accommodations 
for  the  use  of  those  taken  sick  were  established  in  con- 
nection with  these  caravansaries.  Afterward,  when 
monasteries  and  convents  were  established,  they  were 


TEEIR   ORIGIN  AND  DEVELOPMENT.  13 

tlie  resting-places  of  pilgrims,  and  in  these  we  find  there 
were  special  apartments  arranged  for  the  sick.  In  the 
East,  in  the  time  of  the  Emperor  Julian,  these  apart- 
ments for  strangers  and  pauj^ers  in  the  monasteries  were 
•  called  xendochia.  Amonsj  the  Komans  it  was  the  ens- 
tom  to  set  aside  apartments  in  their  houses  for  guests 
which  they  called  liospitalia — and  it  is  from  this  that 
our  word  liospital  is  derived,  and  it  was  from  the  spirit 
of  charity  taught  by(Christ^  stimulated  by  the  necessi- 
ties of  the  pilgrims,  that  our  first  hospitals  originated. 

As  early  as  a.  d.  300  it  is  said  that  several  hospitals 
were  established  for  the  use  of  sick  pilgrims  near  Beth- 
lehem, under  the  direction  of  St.  Jerome,  in  whose  writ- 
ings the  term  "hospital"  first  appears  in  connection 
with  curative  establishments.* 

Besides  the  necessity  of  providing  places  of  shelter 
for  sick  pilgrims,  another  cause  that  influenced  the 
founding  of  hospitals  and  other  charitable  institutions 
was,  that  the  barons  of  the  middle  ages  did  not  distrib- 
ute corn  among  the  poor,  as  was  the  custom  with  the 
Romans ;  and  when  Christianity  was  introduced  into 
the  Roman  Empire  many  slaves  were  set  free  and  be- 
came helpless  paupers.  % o  ff^^'^"^^-'')^^  I'^Wt'^f 

"To  either  St.  Ephraim,  who  died  in  381,  or  St. 
Fabiola,  is  due  the  credit  of  founding  infirmaries,  which  '^ 

were  supported  by  charitable  contributions  for  the  ex-  'J 

elusive  purj^ose  of  treating  the  sick."  ,$ 

Hospitals  were  spoken  of  "  in  the  Council  of  Nice,  < 

A.  D.  325,  as  institutions  well  known  and  deserving  sup- 
port and  encouragement." "" 

The  famous  Hosj^ital  of  Cesarea  was  founded  a.  d. 

'  Dr.  Toner's  "  Contributions  to  the  Annals  of  Progress  in  Medicine.'' 


14  HOSPITALS: 

370.  The  Hotel-Dieu,  perhaps  the  oldest  hospital  in 
Europe  now  in  use,  was  founded  about  a.  d.  600  by 
St.  Landry,  Bishop  of  Paris,  for  all  sick  and  destitute 
persons  of  whatever  sex,  age,  or  condition.  Its  motto 
was  "  Medicus  et  Hospes  " — sick  pilgrims  and  mendi- 
cants all  were  received. 

The  first  hospital  built  in  England  especially  for 
the  sick  was  erected  at  Canterbury  by  Archbishop  Lan- 
franc.  Id  1070  and  in  1208  the  Hospital  of  the  Holy 
Ghost  and  St.  George's  Hospital  were  established  in 
Berlin.  After  this  a  hospital  was  considered  requisite 
for  eveiy  city  to  afford  shelter  to  the  poor  and  sick. 

The  introduction  of  the  leprosy  during  the  Cru- 
sades, and  later  epidemics  of  small-pox  and  cholera, 
necessitated  the  separation  of  the  sick  from  the  well, 
and  to  accomplish  this  many  lazarettos  were  built. 
Lamothe,  in  his  book,  "  Charitable  Legislation,"  says 
that,  in  1226,  there  were  two  thousand  such  institutions 
in  France  alone. 

In  1048  a  school  of  medicine  was  established  at 
Salerno,  and  the  same  year  an  order,  called  the  "  Breth- 
ren of  the  Hospital,"  for  the  care  of  the  sick  in  Jerusa- 
lem, dedicated  to  John  the  Baptist,  was  organized,  and 
in  1118  knightly  vows  were  added.  After  this  broth- 
erhoods of  Hosj^italers  were  formed  and  extended 
through  Europe.  As  the  Crusaders  increased,  the 
brotherhoods  became  richer  and  more  numerous;  and  it 
was  not  uncommon  for  wealthy  persons,  when  dying,  to 
bequeath  theii'  property  to  the  hospital  in  which  they 
had  been  relieved  while  away  from  home.  The  hos- 
pitals established  by  these  brotherhoods  were  always 
near  and  connected  with  a  monastery  or  cathedral.  Of 
their  internal  arrans-ements  but  little  is  kno^vn.      It 


THEIR   ORIOm  AXD  DEVELOPMENT.  15 

seems  that  tlie  kniglits  or  hrotliers  bound '  up  tlie 
wounds,  and  acted  as  pliysicians.  The  earliest  account 
of  physicians  or  surgeons  being  connected  with  a  hos- 
pital among  the  Templars  was  under  John  de  Lastic, 
who  in  1437  defined  the  duty  of  the  physicians  and 
surojeons.' 

In  1456  the  Grand  Hospital  of  Milan  was  opened. 
This  remarkable  building  is  still  in  use  as  a  hospital, 
and  contains  usually  more  than  two  thousand  patients. 
The  buildings  stand  around  scpiare  yards,  the  j^rincipal 
one  being  much  larger  than  the  others,  and  separating 
the  hospital  into  two  parts.  The  main  wards  on  either 
side  of  this  large  court  form  a  cross,  in  the  centre  of 
which  is  a  cupola,  with  an  altar  beneath  it,  where 
divine  service  is  performed  daily  in  sight  of  the 
patients.  These  wards  have  corridors  on  both  sides, 
which  are  not  so  lofty  as  the  ceilings  of  the  wards,  and 
consequently  there  is  plenty  of  room  for  windows  above 
these  passages.  The  ceilings  are  thirty  or  forty  feet 
hio-h,  and  the  floors  covered  with  red  bricks  or  flao;s. 
The  outside  wards  are  nothing  but  sj)acious  corri- 
dors.* The  wards  were  first  warmed  by  open  charcoal- 
braziers. 

This  hospital,  built  at  the  time  when  the  Chui'ch  of 
Rome  was  at  the  height  of  her  power,  and  but  a  short 
time  before  the  Reformation,  is  a  good  example  of  what 
had  been  attained  toward  the  development  of  hospitals, 
and  it  shows  how  much  a  part  of  the  Church  the  insti- 
tution of  hospitals  was.  We  undoubtedly  owe  much 
to  the  Church  of  Rome.  For  centuries  she  was  the 
only  home  and  protector  of  the  Christian  religion.     By 

*  Beckman's  "History  of  Inventions." 

*  Hospitals,  Intirmaries,  and  Dispensatories,  by  F.  Oppert,  1867. 


16  HOSPITALS: 

the  devotion  of  her  adherents,  and  the  comjoleteness 
and  vitality  of  her  organization,  she  successfully  re- 
sisted the  devastations  of  the  barbarians,  and  preserved 
through  the  darkness  of  the  middle  ages  vs^hat  knowl- 
edge we  have  of  the  Greek  and  Eoman  civilization.  In 
youth  all  is  growth  and  progression,  and  change  brings 
strength  and  power ;  but  with  age  change  means  death, 
and  length  of  life  depends  upon  the  power  to  resist 
change.  The  Church  did  not  prove  to  be  an  exception 
to  this  law,  for  since  the  sixteenth  century  she  has  re- 
sisted all  changes  in  hospitals.  A  close  study  of  all 
hospitals  built  subsequent  to  this  period  for  two  hun- 
dred years  on  the  Continent  of  Europe  and  about  one 
hundred  years  in  England,  in  fact  just  as  long  as  the 
Church  of  Rome  had  control  of  the  hospitals,  shows 
that  no  progress  in  their  construction  was  made. 

In  all  of  these  hospitals  the  first  idea  in  the  erection 
was  to  make  the  hospital  a  church  institution,  and  on 
this  account  the  wards  were  clustered  about  the  chapel. 
Add  to  this  idea  of  making  the  hosj)ital  a  cliurcli  insti- 
tution that  of  economy  and  convenience  of  administra- 
tion^ and  take  the  j^lan  of  the  Grand  Hospital  of  Milan 
as  a  model,  and  we  have  the  source  of  our  modern  block 
plan  and  corridor  hospitals ;  nor  do  we  find  that  this 
hospital,  built  in  1456,  was  to  any  extent  improved 
upon  until  science  became  an  important  factor  in  prog- 
ress and  civilization. 

About  the  first  of  the  sixteenth  century  another 
cause  began  to  influence  the  establishment  of  hospitals, 
namely,  the  necessity  of  providing  for  the  care  of  the 
large  numbers  of  sick  and  wounded  incident  to  war. 
From  the  earliest  ages  it  seems  to  have  been  the  cus- 
tom to  have  a  surgeon  or  physician. in  attendance  on 


TEEIR  OEIGm  AXD  DEVELOPMENT.  17 

an  army,  but,  previous  to  tlie  times  of  Ambrose  Pare 
(1560),  tliere  is  no  evidence  tliat  tlie  physician  or  sur- 
geon was  considered  a  necessity,  or  as  being  of  mucli 
consequence  in  military  affairs. 

As  tliere  was  no  special  provision  for  the  wounded 
after  a  battle,  tliey  were  distributed  in  the  nearest 
towns  and  quartered  upon  the  inhabitants.  There  are 
one  or  two  references  by  ancient  historians,  showing 
that  the  wounded  were  sometimes  placed  in  tents,  but 
there  is  no  account  of  such  a  thing  as  a  military  hospi- 
tal. The  soldiers  were  taught  to  dress  their  wounds 
with  oil  and  wine,  and  in  many  cases  left  to  take  care 
of  themselves  when  wounded. 

The  Italians  were  the  first  to  produce  writers  on 
military  surgery  about  the  beginning  of  the  thii'teenth 
centuiy.  Early  in  the  fourteenth  century  the  study  of 
surgery  was  introduced  into  the  Universities  of  Mont- 
pellier  and  Paris,  but  we  find  no  account  of  a  military 
hospital  being  erected  until  1575,  when,  at  the  siege  of 
Metz,  through  the  influence  of  Ambrose  Pare,  the  first 
famous  military  surgeon,  one  was  built.' 

Thus  we  see  that  the  spirit  of  humanity  without 
the  aid  of  science  did  not  make  proper  provision  for 
sick  and  wounded  soldiers.  Three  hundred  years  later, 
when  science  had  developed  into  such  proportions  as  to 
divide  the  control  of  the  world  with  religion  itself,  we 
shall  find  the  experience  afforded  by  the  large  number 
of  sick  and  wounded  incident  to  wars  to  be  by  fiir  the 
most  important  influence  of  all  others  in  bringing  about 
reforms  in  hosj^itals. 

In  1670  Louis  XIY.  beo-an  to  build  the  Hotel  des 
Invalides.     Beckman,  in  his  "  History  of  Inventions," 

^  "  On  the  Establisliment  of  Army  Hospitals,"  by  Edward  A.  Crane,  M.  D. 
3 


18  HOSPITALS: 

speaking  of  this  liospital  says,  "  The  extravagant  mag- 
uificence  of  wliicli  is  rather  a  proof  and  monument  of 
the  profusion  and  joride  of  that  sovereign  than  of  his 
care  for  meritorious  soldiers."  This  is  one  of  the  first 
instances  of  this  personal  monumental  idea  showing 
itself  in  the  construction  of  hospitals. 

One  of  the  first  houses  established  for  the  sick  poor 
was  that  built  at  Rome  by  Fabiola,  a  Roman  lady,  the 
friend  of  St.  Jerome.*  But  this  and  all  other  hospitals 
founded  by  individuals  were  made  church  institutions 
until  the  beginning  of  the  eighteenth  century,  when 
several  hospitals,  such  as  Guy's,  were  founded  in  Eng- 
land by  individuals,  and  the  monumental  idea  began  to 
show  itself  in  the  style  of  building.  Since  then  many 
have  been  built,  and  in  almost  all  the  idea  of  making  a 
monument  has  been  the  first  and  most  important  con- 
sideration in  selecting  the  style  of  building,  and  has 
lately  done  much  to  hinder  the  adoption  of  the  best 
plans,  so  far  as  the  welfare  of  the  patients  is  concerned. 

Before  the  Reformation  in  the  sixteenth  century, 
hospitals,  lazarettos,  and  all  other  charitable  institu- 
tions, were  completely  in  the  hands  of  the  ecclesiastics, 
and  had  become  a  useful  part  of  the  machinery  of  the 
Church  of  Rome,  which  then  in  a  great  measure  directed 
all  the  affairs  of  Europe.  Until  this  time  the  knowl- 
edge of  medicine  and  pretty  much  all  learning  was  con- 
fined to  the  priesthood.  In  fact,  until  the  eighteenth 
century  almost  all  hospitals  were  more  like  our  poor- 
houses  than  the  hospitals  of  to-day.  At  this  period 
positive  science  was  established,  but  the  practical  adap- 
tation of  science  or  inventions  was  only  just  fairly  be- 
gun.    Curative  medicine  was  hardly  in  advance  of  the 

'  Beckraan's  "History  of  Inventions." 


THEIR   ORIGIN  AND  DEVELOPMENT.  19 

time  of  Hippocrates,  and  sanitary  science  was  in  its 
infancy. 

Early  in  tlie  seventeentli  century,  it  is  said  tliat 
Gustavus  Adolplius  of  Sweden  established  the  first 
regular  military  sanitary  service,  but  we  have  found 
nothing  to  show  that  sanitary  science  to  any  extent  in- 
fluenced the  construction  of  hospitals,  certainly  not 
civil  hospitals,  before  the  eighteenth  century.  After 
the  Reformation,  during  the  reign  of  Elizabeth,  the  age 
that  produced  the  founder  of  Inductive  Science,  efforts 
were  made,  on  account  of  the  prevalence  of  the  plague, 
to  bring  about  -improvement  in  dwelling-houses,  by  lim- 
iting the  number  of  inmates  in  each  house,  etc. ;  and  in 
the  seventeenth  century  the  fearful  ravages  of  both  the 
cholera  and  jail  or  typhus  fever  excited  a  general  inter- 
est in  efforts  to  prevent  the  spread  of  these  contagious 
diseases. 

Toward  the  latter  part  of  this  century,  the  writings 
of  Sydenham  did  much  to  improve  the  science  of  medi- 
cine, and  early  in  the  eighteenth  century  we  find  several 
authors  treating  of  air  intelligently.  Among  these  were 
Hoffman  and  Beucrus.  Arbuthnot  wrote  a  valuable 
treatise  on  air,  arguing  from  the  laws  of  physics. 

In  1713  Cardinal  de  Polignac  wrote  "Le  mecanique 
a  Feu,"  in  which  he  treats  of  ventilation,  and  makes  use 
of  the  laws  of  physics  in  giving  plans  for  the  construc- 
tion of  fireplaces,  and  to  him  is  due  the  credit  of  invent- 
ing the  first  machine  for  forcing  ventilation.  He  says  : 
"  It  is  not  the  warmth  of  a  room,  but  its  inequality  of 
temperature  and  want  of  ventilation.,  that  is  the  origin 
of  numerous  maladies ;  we  cannot,  therefore,  be  too  cau- 
tious of  living  in  those  in  wliich  this  dangerous  impu- 
rity of  heat  and  motionless  air  exists,  nor.  remain  too 


20  HOSPITALS: 

long  in  rooms  into  wliicli  temperately  warm  fresh  air 
is  constantly  flowing  and  diftused." '  The  cardinal's 
method  of  heating  the  air  before  it  enters  the  room,  by 
ducts  and  chambers  behind  the  fireplaces,  is  most  scien- 
tific and  ingenious. 

In  1715  Jean  T.  Desaguliers,  a  French  refugee  then 
residing  in  London,  translated  the  work  of  Cardinal  de 
Polignac  (M.  Ganger)  into  English.  In  1723  Desagu- 
liers  was  requested  to  improve  the  ventilation  of  the 
House  of  Commons,  which  before  that  time  had  been 
ventilated  by  means  of  four  holes  in  the  ceiling  con- 
nected with  hollow  pyramids  to  take  off  the  foul  air — 
but  often  cold  air  would  descend  instead. 

Desaguliers  very  ingeniously  arranged  a  fire  with 
flues  to  heat  the  air  in  the  pyramids  or  shafts,  and  thus 
ventilate  the  room.  In  1727  he  designed  a  machine, 
which  by  means  of  pumps  forced  the  fresh  air  in,  and 
the  foul  air  out,  of  mines.  In  his  "  Cour  de  Physique," 
vol.  ii.,  page  474,  he  describes  a  ventilator  which  he 
had  proposed  to  the  Royal  Philoso23hical  Society  for 
"  changing  the  air  of  the  rooms  of  sick  people  in  a  little 
time,  either  by  drawing  out  the  foul  air  or  forcing  in 
fresh  air,  or  doing  both  successively  without  opening 
doors  or  windows,"  which  he  thought  would  be  of  great 
use  in  all  hospitals  and  prisons,  and  also  serve  to  con- 
vey air  into  a  distant  room.''  The  motion  was  given  to 
the  air  and  the  current  established  by  means  of  a  num- 
ber of  fans  revolving  in  a  circular  case — the  exact  prin- 
ciple of  the  fan-ventilator  of  to-day. 

It  was  not  altogether  original,  but  was  the  ajDplica- 

*  Bernan's  "History  and  Art  of  Warming  and  Ventilating,"  vol.  ii., 
p.  3,  London,  1845. 

*  Philosophical  Tranaactions,  and  Bernan's  "History  of  Ventilation." 


THEIR  ORIGIN  AND  DEVELOPMENT.  21 

tion  and  improvement  of  the  plan  proposed  by  Cardinal 
de  Polignac,  and  was  something  like  Popin's  Hessian 
bellows.  This  centrifugal  wheel- ventilator  was  applied 
to  the  Ilouse  of  Commons  in  1736,  and  used  for  seventy- 
five  years.  In  1741  Samuel  Sutton  published  a  i:)lan 
for  drawing  off  the  foul  air  of  ships  by  means  of  pipes 
passing  through  the  fires  and  connecting  with  the  flues, 
thus  by  suction  forcing  out  the  foul  air.  And  about 
the  same  year  (1741)  Stephen  Hales  published  the 
description  of  a  ventilator  that  worked  on  the  j^rinciple 
of  the  bellows. 

During  the  first  half  of  the  eighteenth  century,  in 
Great  Britain  there  is  but  little  to  be  found  in  medical 
works  having  a  direct  bearing  upon  hospital  reform, 
but  there  were  several  important  hospitals  built; 
among  these  was  the  Royal  Infirmary  of  Edinburgh. 

The  medical  school  in  connection  with  the  univer- 
sity, led  by  Alexander  Munro,  had  grown  in  imj^or- 
tance,  and,  as  there  was  no  hospital  then  in  Edinburgh, 
the  professors  and  those  interested  in  the  school  suc- 
ceeded in  establishing  the  Royal  Infirmary  in  1734. 
The  doctors  took  a  deep  interest  in  the  erection  of  the 
building,  as  they  were  at  that  time  the  most  famous  in 
Britain ;  the  plan  adopted  by  them  will  give  a  good 
idea  of  the  progress  tliat  had  been  made  in  hospital-con- 
struction, and  is  interesting  as  being  one  of  the  first  hos- 
pitals erected  with  the  design  of  subserving  the  inter- 
ests of  a  medical  school. 

The  original  building  is  still  standing;  it  consists 
of  a  central  administrative  portion  with  wings  two 
stories  high  on  either  side,  containing  the  wards ;  the 
whole  hospital  is  one  solid  building,  but  the  windows 
are  large  and  opposite,  and  the  number  of  beds  in  each 


22  HOSPITALS: 

ward  is  small  compared  with  tlie  old  cliurcli  liosj^itals. 
In  many  respects  it  shows  j)rogress,  but  it  is  evident 
that  the  controlling  ideas  in  the  plan  of  construction 
were  economy  and  convenience  of  administration. 

Early  in  the  eighteenth  century,  through  the  wait- 
ings and  teachings  of  Boerhaave,  the  Medical  School  of 
Leyden  became  the  most  famous  of  that  period,  and 
held  the  position  of  the  first  medical  school  of  Europe 
for  a  generation.  Boerhaave  was  a  man  of  great  erudi- 
tion, and  it  is  difficult  to  say  to  what  extent  his  teach- 
ings are  original;  at  any  rate,  many  of  his  aphorisms 
will  bear  the  light  of  science  to-day,  and  show  a  com- 
prehensiveness that  extends  to  some  of  the  latest  scien- 
tific discoveries  and  methods  of  treating  disease.  The 
following  two  aphorisms  have  been  selected  as  having 
a  direct  bearing  upon  the  subject  we  have  in  hand : 
Aphorism  245 :  "  But  it  is  more  especially  serviceable, 
in  the  beginning  of  the  cure,  to  make  an  exact  closure 
of  the  wounded  lips  while  bleeding,  and  making  the 
dressings  seldom,  and  very  expeditiously,  carefully  de- 
fending the  parts  in  the  mean  time  from  everything  too 
moist,  oily,  or  relaxing,  and  also  from  the  cnV  itself P 
Aphorism  200,  on  wounds  in  general :  "  The  air  of  the 
patient's  chamber  should  be  always  pure  and  free  from 
putrid  exhalations ;  that  which  is  dry,  and  moderately 
warm  or  temperate,  is  best ;  and  it  should  be  frequently 
renewed  or  changed." 

We  will  not  give  our  explanation  of  these  words, 
but  that  of  one  of  his  j^upils,  Gerard  van  Swieten, 
w^hich  we  find  in  Van  Swieten's  "  Commentaries  on  the 
Aj)horisms  of  Boerhaave,"  published  more  than  a  hun- 
dred years  ago.  On  page  181,  vol.  ii.,  after  giving  the 
above  aj^horisms,  he  says:  "Where  a  great  number  of 


THEIR   OEIGIN  AN'D  DEVELOPMENT.  23 

wounded  patients  lie  together  in  a  liospital,  tlie  air  is 
filled  witli  putrid  exhalations,  whicli  affect  all  of  them, 
and  kill  many  who  otherwise  might  have  been  pre- 
served ;  such  places  should  therefore  have  the  windows 
often  opened,  and  the  air  changed  or  blown  out,  to  re- 
move the  putrid  exhalations.  It  is  indeed  often  ad- 
vised to  perfume  the  place  for  that  purpose ;  but  chang- 
ino;  of  the  air  is  much  more  serviceable  to  the  diseased." 

"  But,  above  all,  those  patients  are  observed  to  suf- 
fer most  for  want  of  fresh  air  who  have  wounds  in  the 
head,  as  we  are  assured  from  observation."  Can  any- 
thing we  have  to  say  to-day  express  more  clearly  the 
danger  of  foul  air  and  the  necessity  of  jDure  air  in  treat- 
ing wounds  successfully  ?  If  Boerhaave  did  not  origi- 
nate these  ideas,  he  at  least  by  his  learning  and  wisdom 
collected  them,  shaped  them  into  living  germs,  and 
planted  them  in  the  minds  of  his  puj^ils  who  were  des- 
tined to  become  the  first  and  prime  movers  in  the  de- 
velopment and  practical  application  of  sanitary  science 
in  treating  the  sick. 

Among  the  pupils  of  Boerhaave,  at  Leyden,  were  Sir 
John  Pringle  and  Gerard  van  Swieten ;  Donald  IMunro 
and  Eichard  Brocklesby  were  also  students  at  Leyden ; 
all  four  are  noted  as  beino;  amonar  the  first  men  who 
wrote  and  taught  the  application  of  sanitary  science  in 
the  construction  and  management  of  military  hospitals. 

Of  books  that  had  a  wide  circulation  we  have  been 
able  to  find  but  a  few  that  treat  of  the  practical  appli- 
cation of  sanitary  science  in  caring  for  the  sick  and 
wounded,  before  the  publication  of  the  writings  of  Sir 
John  Pringle,  and  none  that  will  compare  with  the  ad- 
vanced views  taught  by  him.  In  1750  he  published  a 
scientific  essay  on  antisej^tic  substances  (probably  the 


2i  HOSPITALS: 

first  ou  tliat  subject),  and  in  1752  tlie  first  edition  of 
liis  famous  work  "  Observations  on  tlie  Diseases  of  tlie 
Army"  appeared.  On  page  86,  in  speaking  of  the 
causes  of  disease  in  armies,  lie  says :  "  The  last  source  is 
from  hospitals,  barracks,  transport-ships,  and,  in  a  word, 
from  every  crowded  place  where  the  air  is-  so  pent  up  as 
not  only  to  lose  part  of  its  vital  i^rinciple  by  frequent 
resj^iration,  but  also  to  be  corrupted  by  the  perishable 
matter  of  the  body,  which,  as  it  is  the  most  volatile 
part  of  the  humors,  is  also  the  most  putrescent,"  etc. 

And  again  he  says :  "  As  to  the  disposition  of  hos- 
pitals with  regard  to  preserving  the  j)urity  of  air,  the 
best  rule  is,  to  admit  so  few  patients  into  each  ward 
that  a  person  unacquainted  with  danger  of  bad  air 
mio-ht  imaoine  there  was  room  to  take  in  double  or 
triple  the  number."  And,  when  speaking  of  hospitals 
and  typhus  fever,  he  recommends  barns  and  other  open 
buildings  in  preference  to  closed  houses,  and  says  that 
pure  air  is  of  more  imj)ortance  than  warmth,  and  adds, 
"  It  may  be  received  as  a  maxim  that  the  more  fresh 
air  we  let  into  hospitals  the  less  danger  there  will  be  of 
breeding  this  dangerous  distemper."  He  recommends 
open  fires  as  the  best  method  of  heating,  and  says  sol- 
diers may  be  treated  under  sheds. 

About  this  time,  science  was  making  rapid  progress 
in  all  directions,  and  there  seems  to  have  been  a  general 
awakening  to  the  necessity  of  sanitary  reform. 

In  a  small  volume  of  Van  Swieten's,  j^ublished  in 
1760,  he  gives  the  following  aphorism:  "The  lodging 
of  a  number  of  men  in  a  place  wanting  in  sj^ace  should 
])e  avoided  with  the  greatest  care;  but,  should  it  at  any 
time  become  necessary,  the  air  must  be  renewed  there 
as  often  as  2:)ossible,  whether  the  men  who  are  lodged 


THEIR  ORIGIN  AND  DEVELOPMENT.  25 

togetlier  are  well  or  sick,  for  it  is  from  a  want  of  venti- 
lation tliat  tlie  most  dangerous  diseases  arise,  including 
even  those  wliicli  are  contagious."  ' 

In  1764  Donald  Munro  puLlislied  a  work  "  On  the 
Condition  of  Military  Hospitals."  In  this  he  pro2:)osed 
the  application  in  hosj^itals  of  Sutton's  method  of  venti- 
lating by  means  of  pi23es  or  ducts  opening  into  the  ceil- 
ing of  the  wards  and  connecting  with  the  flues  of  the 
fires,  and  he  also  recommends  the  use  of  large  sheds  or 
wooden  huts,  which  he  saj^s  have  been  tried  by  Eichard 
Brocklesby,  and  found  to  be  the  best  buildings  for 
treating  the  sick  of  the  army  and  navy. 

Long  before  the  time  of  Brocklesby  no  doubt  wood- 
en huts  had  been  used  for  shelterins;  the  sick  durino- 
epidemics,  from  necessity — the  object  being,  to  sepa- 
rate the  diseased  from  the  well,  without  any  design  of 
placing  the  sick  under  the  most  favorable  circumstances 
to  recover. 

In  the  same  year  (1764)  Eichard  Brocklesby  pub- 
lished his  "  Economical  and  Medical  Observations."  In 
an  essay  on  the  most  effectual  means  of  preserving  the 
health  of  seamen,  by  James  Lind,  M.  D.,  published 
1762,  in  London,  we  find  the  first  definite  proposal  on 
the  classification  of  patients.  He  says :  "  In  all  hospi- 
tals, there  should  be  separate  wards  allotted  for  difter- 
ent  diseases,  and  the  foul  wards  in  a  hospital  ought 
always  to  be  the  best  aired,  and,  where  the  contagion 
is  eminently  malignant,  spacious  tents  with  fireplaces 
are  greatly  preferable  to  any  close  ward  or  apartment 
for  dissij^ating  infection,  and  for  the  recovery  of  the  dis- 
eased." 

Although  the  general  interest  in  sanitary  affairs,  and 

'  Crane  "  On  the  Establishment  of  Army  Hospitals." 


26  HOSPITALS: 

tlie  views  and  practical  suggestions  of  tlie  above-men- 
tioned works,  undoubtedly  brought  about  im^Dortant 
reform  in  tlie  management  and  internal  arrangemepts 
of  tlie  Englisli  hospitals,  yet  no  hospital  was  built  on  a 
different  plan  or  that  could  be  considered  an  improve- 
ment on  the  plan  of  the  Eoyal  Infirmary,  except  per- 
haps one  that  was  built  at  Stonehouse,  near  Plymouth, 
England. 

We  have  not  been  able  to  get  a  full  description  of 
the  plan  of  this  hospital ;  Ave  know  that  it  was  com- 
menced in  1756  and  finished  in  1764,  and  used  for  sick 
seamen.  The  wards  were  in  separate  pavilions,  with 
only  twenty  beds  to  the  ward,  and  the  windows  were 
op230site.  This  was  in  all  probability  the  first  "  pavil- 
ion" hospital;  the  name  of  the  architect  was  Rover- 
head,  of  London.  It  was  at  the  time  considered  a 
model  hospital,  and  was  visited  by  members  of  the 
committee  appointed  from  the  French  Academy  of  Sci- 
ences in  1786,  to  report  upon  a  plan  with  which  to 
replace  the  Hotel-Dieu,  and  from  its  detached  buildings 
or  pavilions  they  took  ideas  "which  guided  them  in  pre- 
j)aring  their  famous  report. 

The  improved  plan  of  this  pavilion-hospital  at 
Stonehouse  was  not  adopted  in  England,  nor  do  we 
know  of  any  hospital  built  in  England  on  this  plan 
until  1860,  when  the  Blackburn  Infirmary  was  built 
near  Manchester,  and  this  was  but  a  reflection  of  the 
Stonehouse  plan  from  the  Lariboisiere  Hospital  in 
Paris,  which  was  finished  in  1854:  after  the  plan  sug- 
gested by  the  French  Academy  committee  in  1786, 
fifty-eight  years  before. 

In  the  writings  of  Pringle,  Brocklesby,  Munro,  and 
Lind,  and  in  the  building  of  the  pavilion  hosj^ital  at 


THEIR  PROOBESS  IX  AMERICA.  27 

Stouelionse,  the  spirit  of  sanitary  reform  wliicli  begau 
with  tlie  Keformation  seems  to  have  readied  its  liio'liest 
point  of  development  in  Great  Britain,  in  so  far  as  tlie 
construction  of  hospitals  was  concerned,  and  except  in 
matters  of  internal  arrangements  no  improvements  were 
made,  and  interest  in  the  subject  of  hospital  construc- 
tion seems  to  have  lain  dormant  for  a  century. 

On  the  Continent  up  to  1776,  a  century  ago,  Vv^e 
find  nothing  of  interest  to  record  as  an  improvement  in 
hospitals.  The  progress  of  science  up  to  that  time  prac- 
tically had  not  reached  the  subject  of  hospitals.  The 
civil  hospitals  were  still  in  the  hands  of  the  ecclesias- 
tics; and  even  in  Paris,  then  the  greatest  scientific  cen- 
tre of  the  world,  they  were,  according  to  the  accounts 
of  numerous  authorities,  in  a  shocking  condition. 

AVe  have  traced  the  development  of  hospitals  in 
Europe  up  to  the  time  of  the  Revolutionary  War.  We 
will  now  turn  to  America. 

Prescott,  in  his  "  Conquest  of  Mexico,"  vol.  i.,  p.  48, 
speaking  of  the  Aztec  civilization,  says :  "  I  must  not 
omit  to  notice  here  an  institution  the  introduction  of 
which,  in  the  Old  World,  is  ranked  among  the  benefi- 
cent fruits  of  Christianity.  Hospitals  were  established 
in  the  princij)al  cities,  for  the  cure  of  the  sick,  and  per- 
manent refuge  for  the  disabled  soldiers ;  and  surgeons 
were  placed  over  them  'who  were  so  far  better  than 
those  in  Europe,'  says  an  old  chronicler,  '  that  they  did 
not  i3rotract  the  cure,  in  order  to  increase  the  pay.' " 

Mr.  Prescott  gives,  as  his  authorities  for  the  above 
statements,  "Torquemada,  Monarch.  lud.,  lib.  xii.,  cap. 
6;  lib.  xiv.,  cap.  3;"  " Ixtlilxochitl,  Hist.  Chich.,  MS., 
cap.  67."  On  page  309,  of  the  same  volume,  he  says,  in 
speaking  of  Montezuma,  "  He  showed  a  similar  munifi- 


28  HOSPITALS: 

cent  spirit  in  Lis  public  works,  constructing  and  em- 
bellisliing  tlie  temples,  bringing  water  into  the  capital 
by  new  channels,  and  establishing  a  hospital,  or  retreat 
for  invalid  soldiers,  in  the  city  of  Colhuacan." 

In  answer  to  certain  questions,  General  J.  W. 
Phel];)S,  an  authority  on  the  subject,  writes,  "  There  is 
abundant  evidence  to  show  that  the  Aztecs  came 
from  Eastern  Asia,  and  that  their  civilization  origi- 
nated in  Buddhist  ideas."  Like  the  Buddhists,  their 
knowledge  of  medicine  was  considerable;  but  their 
religion,  so  unlike  that  of  the  Buddhists,  could  not  have 
prompted  the  building  of  hospitals,  for  they  are  sup- 
posed to  have  sacrificed  and  eaten  one  in  a  thousand  of 
their  population .  every  year,  as  a  religious  institution. 
It  is  possible  that  the  idea  of  the  hospital  may  have 
been  directly  derived  from  the  Buddhists,  and  that  it 
was  prompted  by  their  religion  before  this  sank  into 
cannibalism. 

After  America  was  settled  by  Europeans,  it  is  said 
that  a  small  hospital  was  established  at  Quebec  as  early 
as  1639.^ 

The  first  account  of  a  hospital  in  the  territory  now 
known  as  the  United  States  is  given  by  E.  B.  O'Calla- 
ghan,  in  his  "  New  Netherland  Begister."  In  speaking 
of  a  hospital  in  use  on  Manhattan  Island  in  1658,  he 
says :  "  This  hospital  was  established,  at  the  request  of 
,  Surgeon  Hendricksen  Varrevanger,  for  the  reception  of 
sick  soldiers — who  had  been  previously  billeted  on 
private  families — and  for  the  West  India  Company's 
negroes.  In  1679  this  hospital  consisted  of  'five 
houses.' " ' 

^  Dr.  Toners  "Contributions  to  the  Annals  of  Progress  in  Medicine." 
"'  J.  W.  Beekman,  "  Centennial  Address,"  New  York  Hospital,  1871. 


THEIR  PROGRESS  IX  AMERICA.  29 

Early  in  tlie  eigliteentli  century  pest-lionses  were 
establisliecl  at  Salem,  Massaclinsetts,  at  New  York,  and 
Charleston,  and  in  1717  a  liosj)ital  for  contagious  cases 
was  bnilt  at  Boston. 

In  1750  Dr.  Thomas  Bond  originated  a  movement 
to  build  a  hospital  in  the  city  of  Philadelphia.  Dr. 
Bond,  in  Lis  efforts  to  bring  the  matter  before  the  peo- 
ple and  to  secure  a  charter  fi'om  the  provincial  govern- 
ment, was  assisted  by  Benjamin  Franklin,  at  tliat  time 
a  printer  in  Philadelphia.  The  charter  was  granted  on 
the  6tli  of  May,  1751 ;  temporary  buildings  were  used 
till  1755,  when  the  corner-stone  of  the  present  Penn- 
sylvania Hospital  building  was  laid,  but  the  original 
plan  was  not  comj^leted  until  1805.  The  hospital, 
built  on  the  original  plan,  is  now  in  use.  It  consists 
of  a  central  administrative  part,  with  two  wings  of 
wards  two  stories  high,  with  a  basement.  Considering 
the  early  date  at  which  the  plan  was  adopted,  it  was 
a  very  good  one,  and  far  surpasses  the  old  monas- 
tery and  convent  buildings  that  constitute  a  large  part 
of  many  of  the  most  renowned  hospitals  now  in  use 
abroad. 

This  was  the  iirst  chartered  hospital  of  this  country. 
In  1775  four  hundred  and  thirty-five  patients  were  ad- 
mitted into  it.*  The  scientific  and  philosophical  works 
of  Benjamin  Franklin  had  a  marked  influence  in  edu- 
cating the  people  of  this  country  in  the  practical  appli- 
cation of  the  teachings  of  sanitary  science,  and  from  his 
connection  with  the  Pennsylvania  Hospital,  and  his 
writings  on  ventilation,  stoves,  etc.,  it  seems  that  to 
him  is  due  the  credit  of  influencino;  the  selection  of  so 
good  a  plan. 

'  Dr.  G.  B.  Wood,  "Centennial  Address,"  Pennsylvania  Ilospita],  1851. 


30  HOSPITALS: 

Mr.  Beekman,  in  Ms  "  Ceutennial  Address  "  before 
the  Society  of  tlie  New  York  Hospital,  says : 

"In  1771  the  city  of  New  York  was  a  small  town 
of  about  twenty-one  thousand  inhabitants,  scarcely  ex- 
tending on  the  north  as  far  as  St.  Paul's  Church. 

"  The  governors  of  King's  College  (now  Columbia) 
had  established  a  medical  school  on  the  l7th  of  Sep- 
tember, 1767,  and  to  the  exertions  of  two  of  the  pro- 
fessors, Dr.  Samuel  Bard  and  Dr.  John  Jones,  the  New 
York  Hospital  owes  its  origin. 

"  The  charter  was  obtained  in  1771.  The  governors 
empowered  Dr.  Jones  in  1772,  then  intending  to  sail 
for  Europe,  to  make  collections  of  money  and  to  buy 
medicines  and  apparatus  abroad,  and  the  next  year 
decided  to  build  the  hospital  on  a  plan  proj^osed  by 
Dr.  Jones  on  his  return. 

"  On  the  6th  of  March,  1775,  when  hardly  finished, 
the  hospital  was  completely  destroyed  by  fire,  and  was 
not  rebuilt  until  1791.  In  1775  Dr.  Jones  published  a 
little  book  under  the  title  '  Plain  Concise  Practical  Re- 
marks on  the  Treatment  of  Wounds  and  Fractures,  to 
which  is  added  a  Short  Appendix  on  Camp  and  Mili- 
tary Hospitals:  Principally  designed  for  the  Use  of 
Young  Military  Surgeons  in  North  America.' "  This 
little  book  was  very  useful  during  the  Revolution. 

The  first  pages  of  this  Appendix  relate  to  all  hos- 
pitals, and  the  whole  subject  of  hospital  reform  is  con- 
cisely expressed.  In  a  foot-note  an  outline  of  his  j^lan 
for  the  New  York  Hospital  is  given.  As  the  advanced 
views  expressed  in  these  remarks  on  civil  hospitals, 
illustrated  by  the  few  words  on  the  plan,  antedate  by 
more  than  ten  years  any  other  publication  we  have  been 
able  to  find,  we  will  quote  the  following : 


TEEIR  PROGRESS  IN  AMERICA.  31 

"  Among  tlie  variety  of  public  errors  and  abuses  to 
be  met  witb  in  buman  aiFairs,  tbere  is  not  one,  perbaps, 
wbicb  more  loudly  calls  for  a  speedy  and  effectual  refor- 
mation tban  tbe  misajoplied  benevolence  of  bospitals  for 
tbe  sick  and  wounded. 

"  AVe  daily  see  persons  of  every  rank  and  sex  con- 
tributing to  tbese  charities  witb  a  spiiit  of  liberality 
wbicb  does  bonor  to  bumanity,  wbile  many  of  tbem, 
witb  tbe  most  becoming  zeal,  are  devoting  tbeir  time 
and  sacrificing  tbeir  private  interest  to  tbe  care  of  super- 
intending tbe  structure  and  management  of  tbe  bouse ; 
and  yet  an  absurd,  mistaken  economy  bas  bitberto  not 
only  rendered  all  tbis  pious  labor  and  expense,  in  a 
great  measure,  useless,  but  even  fatal  and  destructive 
to  tbe  very  end  and  aim  of  tbe  intended  purpose — tbat 
of  bealing  tbe  diseases  of  tbe  sick  and  poor. 

"  To  those  who  are  unacquainted  with  tbe  subject 
in  question,  it  will  doubtless  appear  a  very  extraordi- 
nary assertion  tbat  tbere  is  not  at  present,  in  the  capi- 
tal of  the  kingdom,  a  single  hospital  constructed  upon 
proper  medical  principles ;  yet  it  is  a  fact  very  gener- 
ally acknowledged  by  the  most  eminent  men  in  tbe 
profession  of  physic  and  surgery  in  England. 

"  If  we  inquire  into  the  cause  of  such  glaring  ab- 
surdities, we  shall  easily  trace  them  to  those  sources 
of  darkness  and  isinorance  from  which  most  of  our 
civil  and  reli2:ious  abuses  have  orio-inated:  but  bow 
they  should  be  continued,  to  disgrace  the  improve- 
ments of  more  enlightened  times,  can  only  be  resolved 
by  reflecting  on  the  pride,  obstinacy,  and  self-interest, 
which  are  too  generally  annexed  to  ancient  errors. 

"  If  great  and  populous  cities  have  been  justly  styled 
the  graves  of  the  human  species,  the  large  and  crowded 


32  HOSPITALS: 

Los^^itals  generally  built  in  tliem  may,  with  equal  trutli 
and  propriety,  be  denominated  tlie  lazarettos  or  pest- 
liouses  of  most  of  tlie  unfortunate  persons  who,  from 
ill-directed  motives  of  compassion,  are  carried  into  tliese 
charities.  In  the  two  great  hospitals  of  St.  Thomas  and 
St.  Bartholomew,  in  London,  about  six  hundred  j^atients 
die  annually,  which  is  about  one  in  thirteen  of  those 
who  are  admitted  as  patients. 

"  In  Paris  it  is  supposed  that  one-third  of  all  who 
die  there  die  in  hospitals.  The  Hotel  Dieu — a  vast 
building  situated  in  the  middle  of  that  great  city — 
receives  about  twenty-two  thousand  persons  annually, 
one-fifth  of  which  number  die  every  year.  It  is  imjDos- 
sible  for  a  man  of  any  humanity  to  walk  through  the 
long  wards  of  this  crowded  hospital,  without  a  mixture 
of  horror  and  commiseration  at  the  sad  spectacle  of  mis- 
ery which  presents  itself.  The  beds  are  placed  in  triple 
rows,  with  four  and  six  patients  in  each  bed ;  and  I 
have  more  than  once,  in  the  morning  rounds,  found  the 
dead  lying  with  the  living;  for,  notwithstanding  the 
great  assiduity  and  tenderness  of  the  nurses,  some  of 
whom  are  women  of  fomily  and  take  the  veil  and  pious- 
ly devote  themselves  to  that  office,  yet  it  is  almost  im- 
2)ossible,  from  the  vast  number  of  patients,  to  bestow 
timely  assistance  upon  every  individual.        , 

"  If  we  compare  the  number  of  patients  who  die  in 
the  county  infirmaries  of  England  with  those  of  the 
London  and  Paris  hospitals,  the  pro23ortional  difference 
will  be  greatly  in  favor  of  the  former — in  the  North- 
ampton Infirmary  one  in  nineteen  dies  annually,  and  in 
that  of  Manchester,  placed  in  a  more  airy  situation,  one 
in  twenty-two ;  and,  although  the  j)utrid  air  of  great 
cities  is  more  unfavorable  to  health  in  general  than  that 


THEIR  PROGRESS  IX  AMERICA.  33 

of  country  towns,  yet  tlie  great  difference  in  mortality 
will  be  found,  upon  a  close  and  fair  examination,  to 
arise  from  tlie  structure  and  crowded  wards  of  the  hos- 
pitals in  overgrown  capitals. 

("  It  is  to  be  hoped  that  the  hospital  lately  built  in 
this  city  will  have  fewer  objections  to  its  plan  than  any 
hospital  hitherto  constructed ;  the  principal  wards — 
which  are  to  contain  no  more  than  eight  beds — are 
thirty-six  feet  in  length,  twenty-four  wide,  and  eighteen 
high ;  they  are  all  well  ventilated,  not  only  from  the 
opposite  disposition  of  the  windows,  but  proper  oj^enings 
in  the  side-walls,  and  the  doors  open  into  a  long  passage 
or  gallery  thoroughly  ventilated  from  north  to  south.' ) 

"  For,  if  to  the  comparison  between  the  mortality  in 
large  city  hospitals  and  those  of  country  towns  we  fur- 
ther add  the  proportional  difference  between  the  last 
and  that  of  private  practice,  it  will  be  found  to  be  in 
favor  of  the  latter.  From  all  which  facts  it  evidently 
appears  how  essentially  necessary  pure  air  is  to  the  cure 
of  diseases  in  general,  and  particularly  those  which  arise 
from  putrescent  causes,  either  internal  or  external. 

"  It  is  computed  that  a  gallon  of  air  is  consumed 
every  minute  by  a  man  in  health,  and  much  more  must 
be  necessary  to  one  who  is  sick,  as  the  morbid  effluvia 
which  are  continually  exhaling  from  all  parts  of  the 
body  and  lungs  must  contaminate  a  larger  portion  of 
the  surrounding  atmosphere,  and  render  it  less  health- 
ful to  breathe  in,  for  animals  are  observed  to  die  much 
sooner  in  foul  air  than  in  vacuo. 

"  But,  the  preceding  facts  not  having  been  sufficient- 
ly understood  or  attended  to,  a  false  economy  has  uni- 

^  Dr.  Jones  here  refers  to  the  New  York  Hospital,  ■which  was  burned 
down  in  1775. 

3 


34  HOSPITALS: 

versally  j)revailed  in  tlie  structure  of  hospitals  for  tlie 
sick;  for  those  tliat  liave  liitlierto  liad  a  principal  direc- 
tion, both  in  the  architecture  and  management  of  them, 
have  confined  their  views  entirely  to  objects  of  conven- 
iency,  cheapness,  or  ornament;  and,  in  one  of  the  last 
hospitals  built  in  London  for  lying-in  women,  there  is 
more  expense  bestowed  on  an  elegant  chapel  in  it  than 
^vould  have  furnished  four  wards. 

"  In  short,  the  physician  and  architect  have,  gener- 
ally, two  very  opposite  and  incompatible  views — the 
latter  laying  out  his  plans  so  as  to  contain  the  greatest 
number  of  persons  in  the  least  possible  space,  whereas 
the  former  always  aims  at  having  the  titmost  room 
which  is  consistent  with  use  and  conveniency. 

"  The  same  false  maxims  of  economy  which  have 
prevailed  in  the  construction  of  hosj)itals  in  large  cities 
are  too  much  adopted  in  the  military  hospitals  of 
camps  and  garrisons,  as  evidently  appears  from  the 
complaints  made  of  them  by  Sir  John  Pringle,  to  '^vhose 
excellent  observations  on  the  diseases  of  the  army  I  am 
principally  indebted  for  the  following  remarks  on  the 
means  of  preventing  diseases  in  camp  or  garrison." 

These  j^^g^s?  written  one  hundred  and  one  years 
ago,  in  their  comprehensiveness  reach  down  to  this  very 
day;  they  show  that  Dr.  Jones  had  studied  the  subject, 
and  was  well  prepared  to  take  advantage  of  his  trip 
abroad,  to  see  understandingly  hospitals  as  they  then 
existed,  ^nd  to  imbibe  fully  the  spirit  of  hosj^ital-reform 
at  that  time  at  work  in  England,  and  soon  to  express 
itself  in  France  through  the  famous  report  of  the  Acad- 
emy of  Sciences. 

Dr.  Jones's  account  gives  us  a  very  good  idea  of  the 
construction  and  sanitary  condition  of  hosjoitals,  just 


TEEIR  PROGRESS  IX  AMERICA.  35 

previous  to  the  Kevoliitionary  War.  All  writers  of 
tliat  period  substantiate  tlie  statements  made  by  Dr. 
Jones,  that  tlie  condition  of  tbe  hospitals  in  France  was 
very  bad ;  but,  if  tlie  death-rate  in  the  London  hosjiitals 
was  only  one  in  thirteen,  their  hygienic  condition  must 
have  been  as  good  as  it  is  to-day.  It  is  interesting  and 
curious  to  compare  this  most  excellent  plan  given  by 
Dr.  Jones  as  that  of  the  New  York  Hospital,  destroyed 
by  fire  more  than  one  hundred  years  ago,  with  the  seven- 
story  building  just  erected  for  the  New  York  Hospital 
on  a  space  of  ground  only  seventy  feet  by  one  hundred 
and  seventy-five  in  extent,  which  is  to  accommodate  one 
hundred  and  fifty  patients.     There  are — 

1.  Basement  containing  dispensary,  and  nearly  on 
a  level  with  the  street. 

2.  Private  wards  and  offices. 

3.  Common  wards. 

4.  Common  wards. 

5.  Common  wards. 

6.  One  ward  and  the  operating-theatre. 

7.  Kitchen  and  drying-room. 

8.  Laundry. 

Under  all  this  is  a  sub-cellar. 

In  the  very  beginning  of  the  Eevolutionary  War 
great  solicitude  was  shown  for  the  proper  care  of  the 
sick  and  wounded  soldiers.  After  the  battle  of  Breed's 
(or  Bunker)  Hill,  a  hosj)ital  was  established  at  Cam- 
bridge "  in  several  private  but  commodious  houses," 
and  Dr.  John  Warren,  a  brother  and  pupil  of  Dr.  Jo- 
seph Warren,  who  fell  while  commanding  the  troops 
in  that  battle,  was  placed  in  charge,  and  soon  after 
this  several  hosj^itals  were  established  around  Boston.* 

'  Bro^vn's  "History  of  the  ITedical  Army  Service  of  the  United  States." 


36  HOSPITALS: 

General  Wasliington,  after  his  first  inspection  of  tliej 
army  as  commander-in-chief,  on  the  21st  of  July,  ad- 
dressed the  following  letter  to  the  President  of  Con- 
gress :  "  I  have  made  inquiry  into  the  establishment  of 
the  hospital,  and  find  it  in  a  very  unsettled  condition. 
There  is  no  principal  director,  nor  any  subordination 
among  the  surgeons;  of  consequence,  disputes  have 
arisen,  and  must  continue  until  it  is  reduced  to  some 
system.  I  could  wish  it  was  immediately  taken  into 
consideration,  as  the  lives  and  health  of  both  oflicers 
and  men  so  much  depend  on  due  regulation  of  this  de- 
j)artment." 

Notwithstandins;  this  kind  consideration  evinced 
for  the  sick  and  wounded  by  the  commander-in-chief, 
and  by  the  whole  American  peojDle  during  the  Eevolu- 
tion,  there  was  much  suffering  on  account  of  the  pover- 
ty of  the  Government  and  the  meagre  resources  of  the 
country,  preventing  the  possibility  of  building  and  con- 
ducting hospitals;  consequently  it  was  a  necessity  to 
make  use  of  all  kinds  of  houses  for  the  purpose  of  treat- 
ing the  sick  and  wounded,  and  we  find  but  little  to 
record  as  adding  to  the  development  of  hospitals.  The 
first  director-generals  of  the  hosj)itals  during  the  Eevo- 
lution,  as  Dr.  John  Morgan,  Dr.  William  Shij^pen,  and 
most  of  the  older  and  controlling  surgeons,  favored 
general  hosj^itals ;  but  there  were  several  advocates  of 
small  regimental  hospitals  after  the  teachings  of  Sir 
John  Pringle,  among  them  Dr.  Benjamin  Eush  and  Dr. 
James  Tilton. 

Dr.  Eush,  in  his  "  Medical  Inquiries  and  Observa- 
tions," s^^eaking  of  the  hospitals  of  the  Eevolution,  says : 

"  Hospitals  are  the  sinks  of  human  life  in  an  army. 
They  robbed  the  United  States  of  more  citizens  than 


THEIR  PROGRESS  IX  AMERICA.  37 

tlie  sword.  Humanity,  economy,  and  pliilosopliy,  all 
concur  in  giving  a  preference  to  the  convenience 
and  wholesome  air  of  private  houses  ;  and,  should  war 
continue  to  be  the  absurd  and  un-Christian  mode  of 
deciding  national  disputes,  it  is  to  be  hoped  that  the 
progress  of  science  will  be  so  great  as  to  prevent,  so  far, 
one  of  its  greatest  calamities,  and  to  produce  an  aboli- 
tion of  hospitals  for  acute  diseases. 

"  Perhaps  there  are  no  cases  of  sickness  in  which 
reason  and  reliojion  do  not  forbid  the  seclusion  of  our 
fellow-creatures  from  the  offices  of  humanity  in  j^rivate 
families,  except  where  they  labor  under  the  calamities 
of  madness  and  the  venereal  disease,  or  where  they  are 
the  subjects  of  some  of  the  operations  of  surgery." 

In  the  besrinnins:  of  the  War  of  1812,  Dr.  James 
Tilton,  of  Delaware,  published  a  small  volume  of  "  Eco- 
nomical Observations  on  Military  Hospitals  and  the 
Prevention  and  Cure  of  Diseases  incident  to  an  Army." 
In  this  hfe  gives  his  exj)erience  during  the  Revolutiou, 
and  describes  the  plan  of  hospital-huts  and  organization, 
presented  by  him  to  Congress  in  1781 ;  on  page  13  he 
says :  "  It  would  be  shocking  to  humanity  to  relate  the 
history  of  our  general  hospitals  in  the  years  1777  and 
1779,  when  it  swallowed  up  at  least  one-half  of  our 
army,  owing  to  a  fatal  tendency  in  the  system  to  throw 
all  the  sick  of  the  army  into  the  general  hospitals; 
whence  crowds,  infection,  and  consequent  mortality,  too 
affecting  to  mention."  Again  he  says :  "  My  brethren 
of  the  faculty  will  probably  think  it  an  interesting  fact 
that  more  surgeons  died  in  the  American  service,  in  pro- 
portion to  their  number,  than  officers  of  the  line ;  a 
strong  evidence  this,  that  infection  is  more  dangerous, 
in  military  life,  than  the  weapons  of  war."     On  page 


38  HOSPITALS: 

47  lie  adds  :  "  The  cardinal  point  or  principle  to  be  ob- 
served in  the  direction  of  all  hospitals  is  to  avoid  infec- 
tion ;  when  this  can  be  done,  the  practice  of  hospitals 
differs  little  or  nothing  from  private  j^ractice.  But, 
where  infection  or  foul  air  is  suffered  to  prevail,  no 
skill  or  address  in  practice  can  much  avail.  The  cause 
must  be  removed  before  the  patient  can  be  relieved  by 
medicine." 

Dr.  Tilton  speaks  favorably  of  tents  for  use  as  hos- 
pitals in  warm  weather,  but  adds:  "In  cold  climates 
and  winter  seasons  some  better  protection  than  tents 
afford  may  be  necessary.  In  such  cases  the  best  hosj^i- 
tal  I  have  ever  contrived  was  upon  the  j^lan  of  an 
Indian  hut.  The  fire  was  built  in  the  midst  of  the 
ward,  without  any  chimney,  and  the  smoke,  circulating 
round  about,  passed  off  through  an  opening  about  four 
inches  wide  in  the  Q'idge  of  the  roof,  etc.  This  w^as  the 
expedient  I  employed  in  the  hard  winter  of  1779-80, 
when  the  army  was  hutted  near  Morristown,  and  I  was 
well  satisfied  with  the  experiment."  He  gives  a  ground- 
plan  and  elevation  for  the  log-hut  hospital. 

Dr.  Tilton  was  appointed  Surgeon-General  of  the 
United  States  Army  in  1813,  when  the  office  was 
created,  and  he  succeeded  in  conducting  the  hospitals 
of  that  war  very  satisfactorily.  Besides  the  works  of 
Drs.  Eush  and  Tilton,  describing  the  American  hospi- 
tals during  the  Revolution  on  the  American  side,  and 
of  Dr.  Jackson  describing  those  of  the  British,,  we  find 
little  of  much  note. 

About  the  time  of  the  Revolutionary  War  in  Amer- 
ica, the  most  important  movement,  certainly  the  one 
that  eventually  had  the  greatest  influence  in  bringing 
about  a  reform  in  the  construction  of  civil  hospitals. 


HISTORY  OF  THEIR  DEYELOPMEFT.  30 

was  made  in  France  just  after  tLe  great  fire  of  1772, 
when  a  part  of  tlie  Hotel-Dieu  was  burned.  Tlie  con- 
dition of  the  hospital  at  that  time  was  such  that  many 
fliYored  its  removaL  The  idea  was,  to  divide  its  in- 
mates among  several  hospitals,  smaller,  and  situated 
farther  from  the  centre  of  the  city.  The  agitation  of 
the  sul;)ject  resulted  in  a  committee  being  aj^pointed 
from  the  Academy  of  Sciences  to  report  upon  a  plan. 
The  committee  was  composed  of  the  most  eminent  men 
of  that  jDeriod,  Tenon,  Bailly,  Lavoisier,  Laplace,  and 
others,  who,  in  their  report  of  the  2 2d  of  November, 
1786,  to  the  ministry  of  Louis  XVL,  urged  the  re- 
moval of  the  hosjntal.  At  that  time  the  inmates  num- 
bered five  thousand,  although  the  number  of  beds  was 
only  about  two  thousand,  all  the  beds  being  double, 
and  many  holding  four  or  six  patients  at  one  time.  • 

The  committee  proposed  to  replace  it  by  four  hospi- 
tals of  twelve  hundred  beds  each.  They  claimed  that 
"  a  sick-ward  should  be  entii^ely  detached  from  other 
buildings,  so  that  its  walls  may  be  constantly  exposed 
to  sun  and  wind,  and  that  draughts  of  fresh  air  may 
constantly  renew  an  atmosphere  which  is  perpetually 
fouling  itself."  They  preferred  that  these  hospitals 
should  only  have  one  floor  of  wards,  but,  as  tins  re- 
quired too  much  ground,  the  j)lan  was  modified.  A 
Government  edict,  June,  1787,  ordered  the  establish- 
ment of  four  hospitals  at  the  four  cardinal  points  of 
Paris,  for  twelve  hundred  beds  each,  and  after  the  plans 
suggested  by  the  committee  of  the  Academy.  The 
political  events  which  followed  prevented  the  execution 
of  the  23roject. 

A  supplementary  report,  dated  the  12th  of  March, 
1788,  lays  down  more  precisely  the  principles  which 


40  HOSPITALS: 

the  plan  of  a  model  liosj^ital  resolved  on  by  the  com- 
mittee represents. 

They  proposed,  as  before,  detached  pavilions  ar- 
ranged in  j)arallel  lines ;  that  the  buildings  for  the 
offices,  kitchens,  pharmacy,  and  other  administrative 
purposes,  should  be  in  front ;  that  the  pavilions  on  one 
side  should  be  for  men,  and  those  on  the  other  side  for 
women,  with  the  chapel  and  operating-room,  etc.,  in  the 
rear  of  the  plot. 

They  proposed  that  the  pavilions  should  be  three 
stories  in  height,  twenty-four  feet  wide  by  one  hundred 
and  sixty-eight  feet  long,  the  ends  of  the  buildings  for 
thirty  feet  being  wider,  and  containing  the  service-rooms 
for  the  wards;  the  wards  to  be  one  hundred  and  eight 
feet  long  and  fourteen  or  fifteen  high.  They  proposed 
that  each  ward  should  contain  thirty-four  to  thirty-six 
beds  in  two  rows,  each  ward  having  its  own  English 
water-closets,  lavatory,  kitchen  for  special  diet,  and  sis- 
ter's or  nurse's  room  with  every  thing  at  hand  for  the 
care  and  comfort  of  the  patients. 

They  proposed  that  each  pavilion  should  be  sepa- 
rated from  the  next  by  a  garden  about  seventy-two  feet 
wide  and  as  long  as  the  building,  with  nothing  in  it  to 
intercept  the  air,  and  to  serve  as  airing-ground  for  the 
patients  of  each  pavilion.  They  proposed  that  the  pa- 
vilions should  be  connected  by  a  corridor  running  round 
the  whole  of  the  central  court,  past  the  foot  of  the  stairs 
in  each  pavilion.  This  corridor  was  not  to  rise  above 
the  ground-floor,  so  as  not  to  intercept  the  circulation 
of  air. 

A  part  of  the  committee  visited  England,  and  along 
with  the  idea  of  the  English  watei^-closets,  baths,  etc., 
they  were  impressed  with  the  necessity  of  limiting  the 


HISTORY  OF  THEIR  DEVELOPMENT.  41 

beds  in  a  ward  to  from  twelve  to  tliirty,  a  custom  en- 
tirely at  variance  with  tliat  wliicL.  prevailed  in  tlie 
Hotel-Dieu,  where  double-beds  at  that  time  were  mul- 
tiplied in  a  ward  to  the  number  of  two  or  three  hun- 
dred. Said  the  Academy  committee :  "  It  is  a  mistake 
to  suppose  that  a  partition-wall  will  divide  a  ward  of 
iifty  beds  into  two  wards  of  twenty-five  beds  each. 
Contiguous,  communicating  w^ards  are  in  reality  but 
one  ward,  and  have  a  common  atmosphere." 

Husson,  from  whose  works  the  above  account  is 
abridged,  says  that  "  the  wards  built  for  La  Pitie,  in 
Paris,  1792-1802,  as  dormitories  for  the  orphans  of, 
soldiers,  for  whose  use  the  building  was  taken,  were 
the  first  instance  of  the  application  of  the  principles 
recommended  by  the  Academy  of  Science."  France 
was  convulsed  with  revolutions,  and  the  practical  re- 
sults of  the  committee's  work  followed  but  slowly  this 
small  be£::innin2:. 

In  1788,  by  royal  order,  the  memoirs  of  Tenon  were 
published,  and  added  a  valuable  work  to  hosj^ital  lit- 
erature. 

The  work  of  John  Howard,  the  philanthropist,  from 
1789  to  1793,  in  visiting  all  the  prisons,  lazarettos,  and 
hospitals,  of  England  and  the  Continent,  by  drawing- 
public  attention  to  the  subject,  caused  not  only  reform 
in  the  sanitary  condition  and  management  of  prisons, 
but  of  hospitals  also.  He  recommends  that  hospitals 
should  be  placed  out  of  town,  and  consist  of  buildings 
not  more  than  two  stories  high,  with  large  and  opposite 
windows,  and  above  all  that  in  a  hospital  there  should 
be  perfect  cleanliness. 

Soon  after  Howard,  appeared  the  philosophical  es- 
says of  Count  Rumford,  who  devoted  his  life  and  a 


42  HOSPITALS: 

large  fortune  to  the  pur2:)ose  of  improving  tlie  condition 
of  tlie  poor.  He  endeavored  to  teacli  the  laboring- 
classes  tlie  practical  application  of  hygiene  in  their 
houses,  and  to  him  is  due  the  credit  of  making  the  first 
efforts  to  systematize  and  direct  charitable  relief,  so  that 
it  might  not  do  more  harm  than  good.  Such  a  work  as 
this  must  have  influenced  the  internal  arrangements  and 
management  of  hosj^itals. 

In  1803,  soon  after  the  state  assumed  control  of  the 
hosj^itals  in  France,  the  report  of  the  Council  General 
did  much  toward  improving  the  management  of  the 
Jaosj)itals  of  Paris.  Keform  in  classification,  cleanliness, 
nursing,  and  change  in  the  administration  in  general, 
were  recommended. 

During  the  first  half  of  the  j)resent  century  many 
hospitals  were  built,  and  several  well-known  works, 
that  had  some  influence  on  hospitals,  were  published ; 
among  these  are  the  writings  of  Morneau,  in  1802  ; 
Pastoret,  in  1808 ;  Cutbush,  in  1808  ;  Clavereau,  in 
1810;  Larrey,  in  1812;  Barton,  in  1814;  Hennan,  in 
1820,  etc.,  etc. ;  and  there  was  a  gradual  im23rovement 
made  in  the  internal  arrangements ;  but,  except  in  mat- 
ters of  this  kind,  nothing  was  advanced  that  could  be 
considered  an  improvement  upon  the  principles  and 
plans  given  in  the  report  of  the  committee  of  the  French 
Academy  of  Sciences. 

In  fact,  with  one  or  two  exceptions,  in  none  of  the 
many  hospitals  established  after  1786 — the  date  of  the 
report — were  the  advanced  views  of  the  committee  car- 
ried out.  Almost  all  the  hosj^itals  built  were  large, 
solid,  many-storied  structures,  with  the  wards  and  ad- 
ministrative offices,  etc.,  all  in  one  building.  In  1829 
a  hospital  was  built  at  Bordeaux  reproducing  the  plan 


HISTORY  OF  TUEIE  DEVELOPMENT.  43 

recommended  by  tlie  committee ;  and  it  was  not  until 
1854,  sixty-eiglit  years  after  the  rej^ort,  wlieu  tlie  Lari- 
boisiere  Avas  finislied,  that  Paris  had  a  hospital  to  show 
as  the  fruits  of  it.  The  plan  of  the  Lariboisiere  is  al- 
most exactly  that  proposed  by  the  committee,  and  is 
only  an  imj^rovement  on  it  in  detail,  excepting,  j)er- 
haps,  the  ventilating  apparatus. 

Previous  to  1859  neither  Eno-land  nor  the  United 
States  had  a  civil  hospital  that  would  compare  favor- 
ably with  the  plan  2:)roposed  by  Dr.  John  Jones  in 
,1773.  One  of  the  first  pavilion-hospitals  built  in  Eng- 
land, after  the  plan  proposed  by  the  French  Academy's 
committee,  was  Blackburn  Infirmary,  in  1859.  The 
first  in  the  United  States  was  the  Episcoj^al  Hospital 
of  Philadelphia,  founded  in  18G0. 

In  Germany  there  seems  to  have  been  but  little 
progress  in  the  development  until  the  early  part  of  the 
present  century,  when  the  plan  of  hospitals  known  as 
the  corridor-hospital  was  introduced  and  very  gener- 
ally adopted.  The  hospitals  of  Eussia  were  modeled 
after  those  of  Germany,  and  were  in  no  respect  better. 

The  next  progressive  step,  after  the  report  of  the 
French  Academy's  committee,  in  the  development  of 
h.osj^itals  was  brought  about  by  the  fearful  death-rate 
of  the  English  and  French  armies  in  the  beginning  of 
the  Crimean  War.  So  great  was  the  mortality,  that 
the  whole  English  j^eople  were  aroused  to  the  necessity 
of  better  provision  being  made  for  the  sick  and  wound- 
ed. Miss  JSTio-htino-ale,  who  had  the  trainins;  as  a  nurse 
at  Kaiserwerth,  selected  a  band  of  thirty-seven  nurses, 
and  left  for  the  seat  of  war  on  the  24th  of  October, 
1854,  and  in  1855  the  Government  a2:)23ointed  a  sanitary 
commission  to  proceed  at  once  to  the  Crimea ;  the  mem- 


44  HOSPITALS: 

berfe  of  tliis  commission  were  John  Sutlierland,  M.  D., 
Hector  G.  Milroy,  M.  D.,  and  Robert  Rawlinson,  Esq., 
C.  E.  Tliey  succeeded  in  introducing  many  valuable 
sanitary  reforms. 

In  1854  Micbel  Levy,  Sanitary  Inspector  of  tlie 
Frencb  army  in  tlie  Crimea,  suggested  tlie  use  of  wood- 
en barracks  or  huts  for  hospitals,  and  at  the  same  time 
proposed  a  permanent  tent-hospital.  It  was  found  by 
experience  that  simple  wooden  huts,  raised  from  the 
ground,  with  double  walls — to  protect  from  the  heat  in 
summer  and  cold  in  winter — with  ridge-ventilation,  and 
heated  by  means  of  open  fires  or  stoves,  gave  far  better 
results  than  any  other  kind  of  building.' 

The  following,  afterward  expressed  by  Dr.  Suther- 
land, will  give  the  best  idea  of  what  was  taught  by  the 
experience  of  the  Crimean  War.  He  says :  "  But,  while 
admitting  that  large  buildings  may  be  improved  if  there 
be  time  for  doing  so,  it  must  be  stated  that  no  more 
disastrous  idea  can  take  possession  of  men's  minds  than 
that  sick  and  maimed  people  ought,  on  grounds  of  hu- 
manity, to  be  packed  into  churches,  barracks,  and  other 
unprepared  buildings,  with  as  little  delay  as  possible. 
This  error  has  slain  its  tens  of  thousands  in  all  wars." 

The  indefatigable  and  j)ractical  work  of  Miss  Night- 
ingale in  the  hospitals  during  the  Crimean  War,  and 
her  masterly-written  answers  to  the  questions  of  the 
"  Commissioners  appointed  to  inquire  into  the  Regula- 
tions affecting  the  Sanitary  Condition  of  the  Army  and 
the  Organization  of  Military  Hospitals,  and  the  Treat- 
ment of  the  Sick  and  Wounded,"  published  in  1858, 
have  justly  made  the  name  of  Florence  Nightingale 

'  Eeport  of  the  Proceedings  of  the  Sanitary  Commission  dispatched  to 
the  Seat  of  War  in  the  East,  1855-'56. 


HISTORY  OF  THEIR  DEVELOPMEXT.  45 

most  fiimoiis  not  only  in  connection  witli  nursing,  Lnt 
hospital-construction  also.  In  1859  tlie  first  edition  of 
her  well-known  book,  "  Notes  on  Hospitals,"  appeared. 

This  book  of  Miss  Nightingale,  on  account  of  its 
real  worth  and  the  earnest,  practical,  and  telling  way  in 
which  it  is  written,  has  done  more  to  bring  about  re- 
form in  hospital-construction  than  any  other  work  ever 
written.  And  her  book,  "  Notes  on  Nursing,"  has  made 
her  name  a  household  word  wherever  the  English  lan- 
guage is  spoken. 

These  two  books  of  Miss  Nightingale  were  the  first 
to  reach  and  educate  the  peojyJe.  The  general  interest 
in  hospital-reform  was  very  great  in  England  for  years 
after  the  Crimean  War,  and  the  discussion  of  the  sub- 
ject between  the  advocates  for  new  and  imj^roved  hos- 
pitals to  replace  the  venerable  old  hospitals,  and  the 
non-progressive  and  conservative  party,  still  shows  it- 
self. The  "  General  Commission  appointed  for  improv- 
ing the  Sanitary  Condition  of  Barracks  and  Hospitals  " 
made  a  report,  April,  1861,  signed  by  John  Sutherland, 
W.  H.  Burrell,  and  Douglas  Galton,  whicli  accej^ted 
the  ex]3erience  of  the  Crimea,  and  the  suggestions  of 
Miss  Nightingale,  and  settled  the  question  in  regard  to 
military  hospitals  by  the  adoption  of  what  is  known  as 
the  barrack-hospital  plan. 

In  answer  to  the  reforms  proposed  by  Miss  Nightin- 
gale, and  to  counteract  the  general  feeling  that  all  old 
hospitals  should  be  replaced  with  new  ones,  the  medi- 
cal of&cers  of  the  Privy  Council,  Dr.  Bristowe  and 
Dr.  Holmes,  after  visiting  almost  every  hosj)ital  in  the 
United  Kingdom,  made  a  most  excellent  but  very  con- 
servative rej)ort.' 

*  Sixth  Report  of  Medical  Officers  of  the  Privy  Council,  Eyre  k  Spottis- 
woode,  London,  1863. 


46  '  HOSPITALS: 

Sir  James  Y.  Simpson  took  uj)  the  subject  and 
brought  forward  statistics  to  show  tlie  relative  mor- 
tality of  private  practice  and  small  hospitals  in  the 
country,  compared  with  the  mortality  of  large  city  hos- 
pitals, and,  in  his  paj)er  on  "  Hospitalism,"  advocates 
small  cottage-hospitals,  outside  the  city  limits.  He  was 
answered  by  Matthews  Duncan  on  the  conservative 
side. 

Lately  the  subject  of  hosj^italism  was  warmly  dis- 
cussed in  the  British  Medical  Association,  and  in  1874 
Mr.  Erichsen  published,  in  book-form,  a  course  of  lect- 
ures oh  "  Hosj^italism."  This  little  book,  in  which  the 
need  of  hos23ital-reform  is  plainly  shown,  not  alone  in 
the  matter  of  construction,  but  especially  in  all  that 
concerns  internal  arrangement,  is  of  very  great  value. 

The  2:>ractical  results  of  the  interest  in  hosj^itals 
brought  about  by  the  Crimean  War  were,  the  building 
of  the  famous  Herbert  Hospital  at  Woolwich,  and  the 
establishing  on  a  sure  basis  the  detached  pavilion-j)lan 
of  hospital-construction,  the  plan  which  had  been  pro- 
posed, and  on  which  a  small  hospital  (Plymouth  Naval 
Hospital)  had  been  erected,  just  one  hundred  years  be- 
fore. The  Herbert  Hospital  is  an  imjorovement  uj^on 
the  Lariboisiere ;  but,  like  it,  is  modeled  after  the  plan 
proposed  by  the  French  Academy's  committee  of  1786 
— the  improvement  being  mainly  in  the  details  of  in- 
ternal arrangement. 

Until  the  buildiDg  of  the  Herbert  HosjDital,  the 
Lariboisiere  was  the  model  hospital  of  the  world. 
Now,  in  the  United  Kingdom,  the  Herbert  Hospital  is 
the  model. 

Since  the  building  of  the  Herbert  Hospital,  several 
hospitals  have  been  erected ;  among  these  the  new  St. 


EISTOEY   OF  THEIR  DEVEL0P2IEXT.  ,       47 

Tliomas's,  wliicli  only  surpasses  tlie  Herbert  in  mag- 
nificence of  construction,  but,  instead  of  two  floors  of 
■wards  to  tlie  pavilion,  lias  three  witli  an  attic,  and  all 
tlie  pavilions  on  one  side  of  tlie  corridor. 

The  Eotherham  Hospital,  lately  finished  (1872), 
has  three  small  one-story  wards.  It  is  the  only  civil 
hospital  completed  on  the  one-story  plan,  that  we  know 
of,  in  England.  One  for  one  hundi^ed"  and  fifty  beds  is 
buildino;  at  Manchester, 

The  influence  of  the  Crimean  experience  did  not  do 
so  much  for  France.  M.  Husson's  well-know^n  work 
was  published  in  1862,  but  nothing  better  than  the 
Lariboisiere  w'as  proposed.  In  Germany  the  corridor- 
hosjDital  had  not  been  improved  upon,  nor  until  within 
the  last  ten  years  had  any  important  progress  been 
made. 

Before  the  interest  in  sanitary  and  hospital  reform 
caused  by  the  Crimean  "War  had  quieted  down,  the 
American  people  had  an  opportunity  aftbrded  them. to 
make  use  of  the  valuable  suggestions  published  in  the 
reports  of  the  English  commission,  and,  in  doing  so, 
succeeded  in  developing  the  most  perfect  s}'stem  of 
army-hospitals  ever  known  to  the  world. 

Early  in  the  late  civil  war  a  sanitary- commission 
was  organized,  of  which  the  Rev.  H.  "W.  Bellows,  13.  D., 
was  chairman.  In  July,  1861,  the  committee  on  hospi- 
tals of  this  commission  reported:  "Your  committee 
venture  to  embody  their  conclusions  in  form  of  sugges- 
tions, and  would  submit  to  the  commission  the  pro- 
priety of  recommending  to  the  Government  that  here- 
after, instead  of  hii'ing  old  buildings  for  general  hospi- 
tals, they  should  order  the  erection  of  a  sufficient  num- 
ber of  wooden   shanties  or   pavilions  of  appropriate 


48  HOSPITALS: 

construction,  and  fully  prorided  witli  ^yater  for  bath- 
ing, washing,  and  water-closets,  and  ample  arrange- 
ments for  ventilation  and  for  securing  warmtli  in  win- 
ter, to  accommodate  from  thirty  to  sixty  each,  and  to 
be  sufficiently  se2:)arated  so  as  not  to  poison  each  other. 
This  smyo-estion  embodies  the  latest  and  best  views  as 
to  the  construction  of  hospitals,  and  its  adoption  would 
save  both  time  and  money."  And  at  the  close  of  the 
October  session  of  the  commission  it  was  understood 
that  the  Government  would  at  once  commence  the  erec- 
tion of  two  cheap  temporary  model  hospitals  at  Wash- 
ington, "  in  conformity  with  j)lans  carefully  prepared  by 
a  committee  of  the  medical  members  of  the  commission, 
and  approved  by  it,  as  embodying  the  latest  results  of 
sanitary  science.  The  23lans  have  been  formally  ap- 
proved by  the  quartermaster-general,  the  commander-in- 
chief,  and  the  medical  director  of  the  Army  of  the 
Potomac,  and  the  ground  for  the  example-building  has 
been  staked  out." ' 

The  medical  members  of  the  commission  were  Wil- 
liam H.  Van  Bureii,  M.  D. ;  Wolcott  Gibbs,  M.  D. ;  Eob- 
ert  C.  Wood,  M.  D. ;  Samuel  G.  Howe,  M.  D. ;  Elisha 
Harris,  M.D.;  C.  K.  Agnew,  M.D.;  J.  S.  Newberry, 
M.  D.  Mr.  F.  L.  Olmsted,  civil  engineer,  was  also  a 
member  of  the  commission. 

The  works  of  Miss  Nightingale  and  the  Crimean 
experience  are  frequently  quoted  by  the  committee,  and 
the  plan  of  army-hospitals  adopted  was  the  practical 
application  of  tlie  temporary  one-story  Crimean  hut 
with  ridge-ventilation,  extended  to  the  size  of  the  wards 
recommended  by  Miss  Nightingale.     The  wards  were 

^  United  States  Sanitary  Commission  Work  and  Purposes,  Kew  York, 
1864. 


HISTORY  OF  THEIR  DEVELOPMEXT.  49 

connected  by  a  corridor,  and  tlie  first  ones  erected  liad 
tlie  pavilions  arranged  on  opposite  sides  of  the  corridor 
after  tlie  plan  of  tlie  Blackburn  lufii-maiy. 

The  water-closets,  nurses'  rooms,  etc.,  were  usuall}' 
placed  at  one  end  of  the  ward,  or  divided  between  the 
two,  the  water-closets  being  at  the  free  extremity,  and 
the  nurse's  room  and  dining-room  next  to  the  corridor. 
The  number  of  beds  in  each  ward  varied  from  twenty- 
five  to  fifty.  The  wards  were  temporary  in  character, 
with  ridge-ventilation,  and  usually  heated  by  stoves. 
The  administrative  buildings  were  separate  from  the 
pavilions  and  connected  with  them  by  the  corridors ; 
the  wards  were  always  one-story  buildings.  In  fact, 
the  plan  really  differed  from  that  recommended  by  Miss 
Nightingale  in  these  respects :  the  pavilions  were  only 
one  story  high,  were  temporary  in  character,  and  always 
had  rido'e-ventilation. 

The  first  hospitals  were  for  only  two  hundred  and 
fifty  beds,  but  later  they  were  much  larger;  one,  the 
"West  Philadelphia  Hospital,"  contained  3,124  beds  in 
wards  of  forty-eight  beds  each. 

The  system  was  thoroughly  tested  during  the  war 
on  a  scale  never  before  equaled,  there  being  at  one  time 
in  the  Government  hospitals  as  many  as  134,000  beds. 
The  success  was  such  that  an  army  averaging  744,346 
men  passed  through  a  four  years'  war  with  an  annual 
death-rate  of  only  eighty-eight  j^er  thousand  from  all 
causes,  and  it  is  estimated  that  thirty-three  out  of  the 
eighty-eight  were  violent  deaths,  leaving  fifty-five  from 
disease  in  one  thousand. 

The  same  system  and  plan  of  hospitals  were  adopted 
by  the  Confederate  army  during  the  Avar. 

The  exj^erience  of  the  war  may  be  said  to  have  de- 
4 


50  HOSPITALS: 

velopei  and  establislied  tlie  following  principles  in  tlie 
construction  of  liosj)itals : 

1.  That  the  hospital  should  be  placed  on  a  large 
area  of  ground,  so  that  the  2:)avilions  can  be  widely 
separated  from  the  administrative  buildings  and  from 
one  another. 

2.  That  the  wards  should  be  onhj  one  story  in 
height,  and  be  ventilated  by  openings  along  the  ridge 
of  the  roof. 

3.  That  the  ward-pavilions  should  be  put  vq)  not  to 
remain  for  generations  to  come,  but  only  so  long  as  they 
are  free  from  infection ;  and  that,  when  once  they  are 
infected,  they  should  be  destroyed,  and  replaced  with 
entirely  new  structures. 

Soon  after  the  war,  one-story  wood  pavilions  of  a 
temporary  character  for  the  treatment  of  contagious 
fevers  were  put  up  on  Blackwell's  Island,  New  York, 
and  in  different  places  in  the  United  States.  Small 
ones  also  were  built  in  connection  with  large  hospitals 
for  infectious  cases ;  but  the  first  complete  civil  hosj)i- 
tal,  constructed  after  plans  used  during  our  American 
war,  is  to  be  found  in  Germany.  In  1867-68  a  one- 
story  ward-pavilion  hospital  was  planned  and  soon  after 
built  in  Leipsic.  The  old  stone  hospital  is  used  as  an 
administrative  building.  There  are  fourteen  one-story 
ward-pavilions,  or  shed-hospitals  as  the  Germans  call 
them.  They  are  frame  l^uildings  filled  in  with  brick, 
one  hundred  feet  long,  thirty-two  feet  wide,  fifteen  feet 
high  at  the  eaves  and  twenty  at  the  ridge.  They  are 
placed  sixty  feet  apart,  raised  four  feet  from  the  ground 
on  stone  piers,  and  are  connected  by  a  corridor.  They 
have  ridge-ventilation.  ' 

Each  ward   or   shed   has    twenty-four    beds,  with 


HISTORY  OF  THEIR  DEVELOPMENT.  51 

nurse's  room,  batlis,  kitchen,  and  closets,  complete. 
Durins*  twelve  montlis,  Prof.  Thiersch,  who  has  charo-e 
of  tlie  surgical  clinic,  performed  two  hundred  and  sixty- 
six  serious  surgical  operations,  and  did  not  lose  a  case 
from  pyaemia ;  while,  prior  to  the  construction  of  the 
new  pavilions,  in  the  old  stone  hospital,  which  is  now 
the  central  building,  he  lost  from  forty  to  fifty  amputa- 
tions from  this  canse  annually. 

In  1867,  at  Berlin,  a  one-story  ward  was  built  in 
connection  with  Charity  Hospital  by  Dr.  Esse.  Kiel 
has  two  stone  one-story  ward-pavilions  used  as  a  garri- 
son hospital,  and  at  Dresden  one-story  ward-j)avilions 
have  been  built. 

Dr.  Stephen  Smith,  of  Kew  York,  wrote  an  essay 
upon  hospital-construction,  and  recommended  a  plan 
for  the  Eoosevelt  Hospital.  The  plan  recommended 
by  Dr.  Smith  in  this  essay  is  very  much  the  same  as 
that  of  Miss  Nightingale.  The  Roosevelt  Hospital, 
opened  in  1^871,  has  one  one-story  pavilion  to  show,  as 
the  influence  of  the  experiences  of  the  war,  but  New 
York  City  has  had  six  other  large  new  hospitals,  all  of 
which  are  massive,  many-storied  buildings,  costing  im- 
mense sums  of  money ;  and  one  of  these,  the  last,  is 
seven  stories,  and  on  a  sj)ace  of  ground  seventy  by  one 
hundred  and  seventy-five  feet. 

In  Boston,  Massachusetts,  the  one-story  pavilion 
plan  with  ridge-ventilation  has  been  adopted,  and  there 
are  two  or  three  pavilions  erected  on  the  grounds  of 
the  Massachusetts  General,  and  one  on  the  ground  of 
the  Boston  City  Hospital,  which  surpass  any  in  this 
country,  except  perhaps  one  lately  constructed  in  Phila- 
delphia. 

The  organization  of  our  Sanitary  Commission  and 


52  HOSPITALS: 

tlie  plans  for  military  liospitals  were  carefully  studied 
and  efficiently  used  by  tlie  Germans  iii  the  late  Franco- 
German  War. 

So  great  was  the  success  in  treating  the  wounded  in 
the  hospitals  constructed  on  the  American  plan,  that 
since  the  war  the  Germans,  in  their  thorough  and  ex- 
haustive way,  have  taken  up  the  subject  with  the  view 
of  applying  these  principles  to  their  civil  hosj)itals. 
Some  of  the  first  men  in  medicine  and  science  have 
Avritten  monographs  on  the  subject,  such  as  Yirchow, 
Steinberg,  Esse,  Esmarch,  etc.,  and  some  of  the  profess- 
ors of  hygiene  and  surgery  take  uj)  hospital-construction 
as  a  part  of  their  course  in  lecturing  to  students. 

Within  the  past  ten  years  several  books  and  many 
monographs  and  papers  have  been  published  on  the 
subject  of  hospitals,  which  we  have  not  mentioned. 
Among  the  books  are :  "  On  the  Construction  of  Hospi- 
tals," by  Douglas  Galton,  18G9  ;  "  Handy  Book  on  Cot- 
tage-Hosjoitals,"  by  Horace  SAvete,  1870;^  "Notes  on 
Lying-in  Institutions,"  by  Florence  Nightingale,  1871 ; 
and  "  Hospital  Construction  and  Organization,"  Johns 
Hopkins  Hospital,  1875.  Through  the  munificence  of 
the  late  Johns  Hopkins,  the  trustees  of  the  Johns  Hop- 
kins Hospital,  of  Baltimore,  have  at  their  command 
three  million  dollars  ($3,000,000),  and  fourteen  (14) 
acres  of  land  to  establish  a  General  Hospital  of  three 
hundred  (300)  beds.  We  trust  they  will  build  a 
model  hospital  embodying  all  the  late  improvements, 
which  will  Tje  worthy  of  the  Centennial  Year  of  our 
Kepublic. 


CONCLUSION  AS  TO  THEIR  ORIGIN.  53 

CONCLUSIOX  AS  TO  THE  ORIGIN  OF  HOSPITALS. 

The  cliief  object  aimed  at  in  a  liospital  is  to  pre- 
serve life  and  relieve  suffering.  Every  living  tiling  has 
a  certain  amount  of  power  to  repair  itself  wlien  injured, 
and  everytliing  that  lias  life  Las  the  power  given  it  to 
resist  to  some  extent  that  which  tends  to  destroy  it.  A 
tree  will  grow  more  wood  on  that  side  sustaining  the 
greatest  strain  of  a  prevailing  wind,  and  will  grow  to  a 
great  height  before  spreading,  if  the  shrubs  and  trees 
around  make  this  necessary,  to  enable  it  to  get  its  share 
of  sunlight.  The  higher  the  organization,  the  greater 
is  this  power  of  self-protection.  When  we  reach  living 
things  which  have  a  nervous  system,  this  power  of  self- 
protection  becomes  more  marked  and  is  called  the  in- 
stinct of  self-preservation.  As  we  ascend  the  scale  of 
animal  life  this  instinct  gradually  widens  its  circle  of 
influence,  and  includes  not  only  self  but  those  of  their 
kind.  Before  we  reach  man,  we  see  undoubted  in- 
stances of  mutual  sympathy  and  even  love  evinced  by 
the  individual  members  of  more  than  one  race  of  ani- 
mals for  others  not  only  of  the  same  species,  but  of 
entirely  different  families. 

The  idea  of  curing  disease  seems  to  be  plainly  fore- 
shadowed in  the  instincts  of  animals.     The  sick  doQ- 

O 

will  seek  and  chew  his  medicine-grass,  which,  when 
well,  he  never  touches  ;  the  cattle  of  the  pine- wood  dis- 
tricts, where  phosphorus  is  wanting  in  the  grass,  will 
deliberately  hunt  up  and  chew  bones  which  under  oth- 
er circumstances  they  would  not  eat. 

In  the  crude  develo2;)ment  of  religion  and  of  the 
curative  art  these  will  invariably  be  found  associated 
in  the  same  individual.     The  medicine-man  is  the  priest. 


54  HOSPITALS: 

and  the  wise  man  wlio  cures  tlie  evil  spirit  is  the  doctor 
Society  follows  tlie  general  law  of  develoj^ment  of  organ 
isms,  viz.,  tlie  growth  of  special  organs  for  special  func^ 
tions,  which  become  more  distinct  one  from  the  other, 
yet  at  the  same  time  more  dependent  one  upon  the  other 
We  therefore  find,  in  higher  civilizations,  doctors  of  dis 
ease  distinct  from  priests ;  and,  in  the  highest  and  most 
complete  civilization  of  all,  the  priest  making  use  of 
the  doctor  of  medicine  to  helj)  him  do  his  work  of 
charity.     The  hospital  is  the  outcome. 

It  is  true  that  hospitals  nowadays  are  often  organ- 
ized and  carried  on  independently  of  religious  consider- 
ations, purely  on  utilitarian  grounds,  to  protect  the  well 
from  infectious  and  contagious  disease  ;  but  this  2')resup- 
poses  a  knowledge  of  disease  that  did  not  exist  at  the 
date  of  the  origin  of  the  first  hospitals.  Charity  and 
brotherly  love  influenced  men  and  took  shape  in  I'eli- 
gious  organizations  long  before  sanitary  science  existed, 
or  made  itself  felt  throuo'h  the  art  of  medicine. 

History  shows  us  that  the  credit  of  the  origin  of  the 
first  hospitals  is  not  due  to  medicine,  but  to  religion. 

So  far  as  our  knowledge  of  history  goes,  and  as  we 
have  shown  in  the  foregoing  resume,  we  find  that  hos- 
pitals, as  we  understand  them,  have  been  the  outcome 
of  only  two  or  three  civilizations,  namely,  that  of  Buddh- 
ism, the  fire-worshipers,  and  the  Christian  civilization. 
In  what  way  can  this  be  accounted  for  ?  It  cannot  be 
due  to  the  degree  of  civilization,  for  both  Greece  and 
Kome,  in  many  ways,  reached  a  higher  state  of  civiliza- 
tion than  did  the  early  followers  of  Buddha  or  Christ ; 
and  yet,  hosj^itals  for  the  sick  poor  did  not  exist  to  any 
extent,  if  at  all,  among  them.  It  may  be  said  that  their 
laws  were  so  j^erfect  and  efficiently  carried  out,  that 


CONCLUSION  AS  TO  THEIR  0RIGI2i.  55 

liosj^ital's  sucli  as  we  Lave  were  not  needed ;  but  hos- 
pitals must  have  been  needed  after  battles,  wLen  tlie 
soldiers  were  far  removed  from  tlieir  homes.  A  more 
plausible  excuse  would  be  to  say  that  the  science  of 
medicine  had  not  advanced  to  the  same  extent  as  amoni^: 
the  Buddhists  and  early  Christians. 

We  cannot  sj^eak  so  confidently  about  medicine 
among  the  Buddhists ;  but  we  know  that,  at  the  time  of 
the  founding  of  the  first  hospitals  by  Christians,  medi- 
cine was  not  in  advance  of  the  time  of  Hippocrates.  If 
the  Buddhists  did  excel  in  medicine,  judging  by  the  ex- 
perience of  to-day,  it  is  more  than  probable  that  much 
of  this  knowledge  was  acquired  from  the  advantages 
afforded  by  their  hospitals  for  the  study  and  practice 
of  medicine.  There  was  nothing  in  the  religion  of 
either  the  Greeks  or  Romans  that  made  life  sacred,  or 
that  taught  brotherly  love.  Physically  and  intellectu- 
ally they  reached  a  high  state  of  development,  but  they 
made  morally  but  little  progress.  The  Buddhist,  taught 
to  believe  that  every  living  creature  is  sacred,  does  all 
he  can  to  prolong  life;  and  to  this  eud  he  builds  hospi- 
tals, not  only  for  men,  but  for  animals  and  even  insects. 
The  Christian,  following  in  the  footsteps  of  his  Master, 
extends  his  love  and  sympathy  to  all  mankind,  and,  in 
his  efforts  to  show  his  sympathy  by  his  acts,  he  builds 
hospitals  to  prolong  life  and  to  relieve  his  suffering  fel- 
low-beings. 

2-10- >'*■''' 


CHAPTER    II. 

EELATIONS    OF   HOSPITALS   TO   PAUPEEISM. 

Hospitals  may  be  classed  as  follows  : 

1.  Public  eleemosynary  hospitals  founded,  support- 
ed, and  managed,  by  tlie  state  or  municipal  authority. 

2.  Public  eleemosynary  hospitals  founded  usually 
by  an  individual,  then  incorporated  under  a  charter, 
given  to  a  number  of  citizens  as  an  association,  support- 
ed by  endowment  and  by  voluntary  contributions,  and 
managed  by  an  honorary  board  selected  from  the  mem- 
bers of  the  society. 

3.  Army  and  navy  hospitals  established,  sui^ported, 
and  managed,  by  the  state  or  government. 

4.  Church  eleemosynary  hosj)itals  founded,  support- 
ed, and  managed,  by  a  number  of  persons  representing 
a  sect  or  church. 

5.  Private  hospitals  carried  on  in  the  interests  of 
individuals. 

Civil  hospitals  may  be  divided  according  to  the 
classes  of  diseases  treated  in  them : 

1.  General  hospitals  for  the  treatment  of  medical 
and  surgical  diseases  that  are  not  contagious  or  infec- 
tious. As  a  rule,  general  hospitals  have  one  or  more 
departments  for  the  treatment  of  special  cases  connected 
with  them. 


NECESSITY  FOR  HOSPITALS.  57 

2.  Special  liospitals — 
For  cLildren ; 
For  lying-in  women  ; 
For  fevers,  as  small-pox,  tyj^lius,  etc. ; 
For  diseases  of  women  ; 
For  eye  and  ear  ; 
For  throat ; 
For  epileptics ; 
For  incurables; 
For  crippled ; 
For  convalescents ; 
For  insane,  etc.,  etc. 
Civilization  has  not  reached  that  state  of  perfection 
in  which  hospitals  can  be  dispensed  with. 

As  long  as  armies  exist,  hospitals  will  be  necessary. 
Soldiers  removed  from  their  homes,  when  sick,  must  be 
provided  with  special  accommodations ;  and  after  a 
battle  the  vast  number  of  wounded  cannot  be  properly 
cared  for  except  in  hospitals  constructed  esj^ecially  for 
the  purpose. 

During  epidemics  of  contagious  and  infectious  dis- 
eases it  becomes  a  necessity  to  separate  those  infected 
from  the  well,  and  for  their  accommodation  hospitals 
must  be  erected. 

In  every  community,  especially  in  large  cities,  there 
is  always  a  certain  number  of  paupers  without  any 
liomes^  who  must  be  cared  for  when  sick,  and  the  only 
practical  way  of  providing  for  them  is  to  establish  hos- 
pitals. 

In  large  cities  2;)rovision  must  be  made  for  street- 
casualties,  and  hospital-accommodations  are  neces- 
sary. 

Lastly,  on  account  of  difficulty  in  making  suitable 


58  RELATIONS  OF  HOSPITALS  TO  PAUPERISM. 

provision  for  the  insane  in  jjrivate  houses,  hospitals  or 
asylums  for  the  insane  are  necessary. 

Throusrhout  the  Christian  civilized  nations  of  the 
world  the  necessity  for  the  establishment  of  hospitals, 
on  account  of  the  above  reasons,  is  recognized.  Every 
military  post,  where  considerable  numbers  of  soldiers 
are  stationed,  has  its  hospital ;  and  no  army  outfit  is 
complete  without  S]3ecial  arrangements  for  the  erection 
of  suitable  hospitals  for  the  reception  of  the  wounded. 
Every  city  either  has  ready  or  speedily  erects  hospitals 
to  receive  the  infected  duiing  contagious  epidemics,  and 
all  cities  and  large  towns  have  hospitals  for  the  accom- 
modation of  the  sick  poor.  In  every  country  many  in- 
sane-asylums, both  public  and  j^rivate,  are  found. 

Army  hospitals  are  necessary,  and  hospitals  for  the 
insane  and  for  contagious  and  infectious  cases  are  neces- 
sary ;  and  their  size  and  number  must  be  regulated  as 
the  circumstances  demand.  But,  in  regulating  the  hos- 
pital accommodations  for  the  sick  poor,  necessity  does 
not  so  definitely  fix  a  limit,  and  many  perplexing  ques- 
tions arise. 

In  this  country,  in  all  large  cities,  any  one  repre- 
senting himself  as  poor  and  sick  can  apj^ly  either  to  the 
public  hosj)itals  sui^ported  by  the  State  or  to  hosj^itals 
supported  by  voluntary  contributions ;  and,  if,  on  a  sim- 
ple onedical  examination,  his  disease  is  of  the  class  treat- 
ed in  the  particular  hospital — and  there  are  hosj^itals 
for  every  disease — he  is  admitted  without  reference  as 
to  whether'  he  has  a  home,  and  in  many  cases  without 
any  special  iaquiry  or  investigation  as  to  his  circum- 
stances. 

In  some  places,  as  New  York  City,  hospitals  are  so 
numerous,  and  admission  to  them  so  freely  granted, 


INCREASE  AND   COST  QF  CEARITIES.  50 

tliat  tliere  is  little  or  no  restraint  on  im^^ostors.  If  re- 
fused admission  to  one  institution,  tliey  go  to  another, 
and  receive  treatment  and  care  witliout  cost,  wlien  they 
are  fully  able  to  provide  for  themselves.  And  so  nu- 
merous are  the  disj)ensaries  where  medicines  and  medical 
advice  can  be  obtained  free  of  cost,  merely  for  the  ask- 
ing, and  so  easily  and  readily  can  care  and  attention  be 
had  in  free  hospitals,  that  the  poor  liave  no  necessity  to 
make  provision  for  sickness,  nor  any  inducement  to 
guard  against  disease,  and  so  avoid  the  trouble  and 
expense  incident  to  sickness. 

It  is  estimated  that  about  $10,000,000  are  expended 
in  public  and  private  charities  annually  in  tke  city  of 
New  York,  a  city  of  one  million  inhabitants.  A  consid- 
erable portion  of  this  sum  is  expended  on  the  hospitals, 
which  alone  contain  more  than  6,000  beds,  not  includ- 
ing insane  or  other  asylums,  but  only  institutions  known 
by  the  name  of  hospitals.  About  4,000  of  the  6,000 
beds  are  in  pnblic  city  or  State  hospitals,  the  remaining 
2,000  being  in  hospitals  suj)ported  by  voluntary  chari- 
ty. The  official  reports  of  tlie  thirty-odd  free  dispensa- 
ries give  307,060  as  the  number  of  patients  applying 
and  receiving  treatment  in  1875  at  the  dispensaries, 
against  20,031  treated  at  their  homes  by  these  insti- 
tutions. 

To  say  that  $10,000,000  are  exj^ended  in  charities, 
that  there  are  6,000  free  beds  in  the  hospitals,  ahd  that 
over  300,000  persons  receive  medicine  and  medical 
advice  free  of  cost  at  tke  dispensaries,  is  certainly  evi- 
dence of  the  generosity  and  Christian  spirit  of  charity 
that  prevail.  But,  when  looked  at  in  a  direct,  practical 
way,  these  figures  show  something  else.  If  these  official 
reports  are  to  he  relied  %i])on^  then,  in  a  population  of 


60  RELATIONS  OF  HOSPITALS  TO  PAUPERISM. 

one  million,  over  300,000  persons  receive  alms  every 
year ;  or  about  one  in  every  three  of  tlie  peoj^le  is  w^ill- 
ing  to,  and  does,  take  alms  !  We  have  added  together 
the  numbers  reported  in  the  "  Hand-book  of  the  Benevo- 
lent Institutions  and  Charities  of  New  York  in  1876," 
as  being  the  number  of  patients  treated  by  the  disj)ensa- 
ries  in  1875,  and  the  sum  total  is,  as  stated  above,  over 
300,000.  We  doubt  if  the  number  of  individuals  is  so 
large,  for  it  is  the  custom  of  some  dispensaries  to  count 
each  visit  a  patient  makes  as  a  patient  treated ;  but  the 
actual  number  is  immense,  and  increasing  out  of  all  pro- 
portion to  the  increase  of  population. 

The  truth  is,  the  majority  of  our  hospitals,  as  they 
are  at  present  managed^  are  liable^to  do  more  harm  than 
good.  Apparently  they  do  much  good,  and  for  the 
time  do  relieve  suffering  and  want,  but  in  the  end  they 
may  do  much  harm.  Giving  help  too  readily,  even 
during  sickness,  is  hurtful ;  and  when  it  is  offered  free- 
ly, without  the  certain  knowledge  that  it  is  really 
needed,  it  very  naturally  removes  the  healthful  stimu- 
lus of  necessity,  the  dread  of  which  prompts  every  indi- 
vidual to  guard  against  and  provide  for  the  misfortune 
of  sickness. 

The  dispensaries,  as  they  are  now  managed,  without 
any  certain  knowledge  as  to  the  need  of  the  hel])  they 
give,  are  nothing  less  than  a  promiscuous  charity  exact- 
ly similar  to  the  notorious  "  soup-kitchens,"  medicine 
being  substituted  for  soup.  They  offer  to  the  ignorant 
and  poor  an  easy  and  ever-ready  inducement  to  take 
alms.  They. are  the  first  stepping-stones  to  the  degra- 
dation of  pauperism.  The  self  respect  of  an  individual 
is  injured  the  moment  he  accepts  alms,  and  a  habit  of 
taking  alms  invariably  tends  to  a  complete  loss  of  self- 


EDUCATION  TO  REPLACE  AL2IS.  01 

• 
respect  aud   consequent  degradation.     It  matters  but 
little  whether  alms  be  medicine  or  food,  the  principle 
remains  the  same. 

The  hungry  must  be  fed ;  but  we  know  that,  instead 
of  continuing  to  feed  the  hungry,  and  gradually  destroy- 
ing their  power  to  hel]o  themselves,  it  is  infinitely  bet- 
ter to  teach  them  self-help,  and  to  seek  out  and  remove 
the  cause  that  induced  the  miserable  condition  of  help- 
lessness. For  exactly  the  same  reason,  would  it  not  be 
better  to  teach  the  poor  how  to  avoid  getting  sick,  and 
by  every  means  in  our  power  remove  the  causes  that  in- 
duce disease  among  them,  rather  than  to  offer  them  the 
best  care  and  attention,  without  being  sure  that  they 
need  help,  thus  teaching  them  to  become  careless  about 
avoiding  sickness  ? 

It  would  be  more  creditable  to  the  citizens  of  Xew 
York,  if  they  could  say  that  no  such  institution  as  a 
pauper  hospital  was  needed  within  the  limits  of  the 
city,  than  it  is  to  be  able  to  say  that  two  hundred  es- 
tablished charitable  institutions  and  oro'anizations  are 
maintained;  and  instead  of  so  many  millions  being 
spent  in  cariug  for  the  sick,  would  it  not  be  better  if 
the  same  money,  or  perhaps  only  a  small  part  of  it, 
were  spent  in  carrying  out  sanitary  works,  and  teach- 
ing the  people  the  laws  of  health  ? 

Suppose  that,  during  the  prevalence  of  an  epidemic 
of  a  contao;ious  disease,  the  authorities  should  content 
themselves  with  providing  for  those  infected,  and  neg- 
lect to  take  the  necessary  steps  to  remove  the  cause  of 
the  disease  by  doing  all  that  sanitary  science  indicated : 
they  would  soon  be  called  to  account  for  neglect  of 
duty.  It  is  a  well-known  fact  in  science  that  the  great 
majority  of  the  cases  of  disease  treated  in  our  hospitals 


62  RELATIONS  OF  HOSPITALS   TO  PAUPERISM. 

are  induced  by  the  bad  sanitaiy  condition  of  the  homes 
of  the  poor,  and  by  the  direct  violation,  through  igno- 
rance, of  the  plainest  hygienic  laws ;  yet  what  direct 
steps  are  taken  to  correct  this  constantly-acting  cause 
of  sickness?  The  Health  Department  of  New  York 
City  is  expected  to  do  little  else  than  prevent  eiDidem- 
ics  of  contagious  and  infectious  diseases.  The  meagre 
appropriation  prevents  them  from  doing  much  more. 

This  statement  concerning  the  hospitals  and  chari- 
ties of  New  York  City  cannot  be  called  a  fair  example 
of  the  condition  in  smaller  places,  but  it  shows  very 
plainly  and  truthfully  the  prevailing  faults  in  the  ad- 
ministration of  charities  throus^hout  the  countrv.  If 
the  results  in  smaller  places  are  not  so  bad,  it  is  due  to 
local  circumstances,  and  not  to  a  better  understanding 
of  the  subject,  nor  to  the  adoption  of  a  more  enlight- 
ened system. 

The  circumstances  are  very  much  in  favor  of  the 
smaller  cities  and  towns.  Leaving  out  the  many  well- 
known  causes  that  tend  to  generate  pauperism,  and  thus 
increase  the  relative  number  of  paupers  in  a  large  city, 
which  do  not  exist  in  towns  or  small  cities,  the  main 
reason  that  charity  does  not  do  so  much  harm  in  the 
latter  is,  that  the  circumstances  and  the  character  of 
every  one  are  well  known  to  the  people,  and  this  per- 
sonal knowledge  guides  and  directs  the  givers  of  chari- 
ty ;  whereas,  in  the  large  cities,  it  is  seldom  that  the 
giver  of  charity  knows  to  whom  he  is  giving,  and  per- 
sonal hioioledge  rarely  exists  at  all ;  when  it  does,  it  is 
usually  of  such  a  character  as  to  be  of  but  little  prac- 
tical value.  The  difference  between  the  life  of  the 
rich  and  of  the  poor  is  so  great  that  the  rich  cannot 
comprehend  the  real  needs  of  the  poor.     Charity  with- 


PERSONAL  RELATIONS  IN  CHARITY.  G3 

out  tliis  relation  is  like  a  man  with  a  lieart,  muscles, 
and  a  spinal  cord,  to  respond  to  external  influences,  but 
Tvitliout  a  head  and  the  brains  to  coordinate  and  direct 
his  acts.  Unless  these  personal  relations  exist  between 
those  who  give  and  those  who  receive,  no  act  of  generos- 
ity deserves  the  name  of  that  charity  which  "  blesseth 
twice,"  for  gratitude  is  not  developed  in  those  receiv- 
ing help ;  they  give  nothing  in  return  for  what  they 
receive.  Experience  teaches  that  to  do  for  an  indi- 
vidual that  which  it  is  possible  for  him  to  do  for  him- 
self will  invariably  tend  to  harm,  unless  he  gives  in 
return  an  equivalent  either  by  actual  payment  or  in 
gratitude.  And  experience  also  teaches  that  human 
nature  can  only  feel  gratitude  toward  an  individual. 
In  religion,  God  is  represented  as  an  individual,  and  for 
all  his  great  blessings  we  are  told  to  "love  him  with 
all  our  heart,  with  all  our  mind,  and  with  all  our  soul." 
We  are  not  what  we  should  be  unless  we  give  an  equiv- 
alent for  all  we  receive.  When  the  king  was  the  state, 
he  could  give  to  the  j^oor,  and  receive  love  and  loyalty 
in  return ;  but  now  the  people,  the  voters,  the  paupers 
themselves,  are  a  large  part  of  the  state,  and  paupers 
take  their  alms  from  the  state  as  a  riglit. 

Besides  this  tendency  in  hospitals,  as  charitable  in- 
stitutions, to  increase  pauperism,  another  serious  objec- 
tion to  the  use  of  public  hospitals  for  the  purpose  of 
treating  the  sick  beyond  the  extent  absolutely  demand- 
ed by  necessity  is,  that  every  time  an  individual  is  re- 
moved from  his  home — let  that  home  be  never  so  hum- 
ble— and  taken  to  a  hospital,  the  family  as  an  institu- 
tion receives  a  blow.  Then,  too,  except  to  those  already 
degraded,  life  in  a  paujDer  hospital,  especially  with  the 
young,  is  hardening  to   the   feelings,  while  in  many 


04:  EELATIOXS  OF  HOSPITALS   TO  PAUPERISM. 

cases  it  subjects  tlie  moral  to  tlie  influence  of  tlie  im- 
moral. 

Another  objection  to  hos2:)itals  is  the  bad  sanitary- 
condition  of  many  of  them,  and  unless  this  is  improved, 
both  as  to  the  plan  and  the  construction  of  the  build- 
ings, and  the  general  and  internal  management,  so  as  to 
give  a  smaller  "death-rate,  and  fewer  deaths  from  hosjDi- 
tal- diseases,  than  in  the  vast  majority  of  hospitals  nov^ 
in  use,  it  will  be  decidedly  better,  on  sanitary  grounds 
alone,  to  treat  in  their  homes  all  the  sick  poor  who 
have  homes,  even  though  they  may  be  very  bad  and 
unhealthy  places  to  live  in.  As  to  the  expense  of  treat- 
ing the  poor  at  their  homes,  it  certainly  would  not  be 
greater  than  the  expense  of  running  the  hospitals,  if  the 
interest-money  is  added  w^liich  could  be  had  from  the 
immense  sums  that  are  sunk  in  the  massive,  many- 
storied  hospital-buildings  and  the  expensive  city  lots 
on  which  they  stand. 

But,  as  poor-relief  is  now  administered  (and  no 
doubt  under  the  best  system  that  could  be  devised),  a 
certain  number  of  hospitals  for  treating  the  sick  poor 
will  be  necessary.  When  j^roperly  constructed  and 
managed,  they  are  a  great  blessing  to  the  poor ;  while, 
from  the  many  advantages  they  aflbrd  for  the  study  and 
teaching  of  clinical  medicine  and  nursing,  they  are  of 
incalculable  value  to  the  whole  community.  Without 
hospitals  the  diflaculties  in  teaching  practical  medicine 
would  be  very  great,  and  the  whole  method  of  giving 
clinical  instruction  would  be  changed.  A  medical 
school  without  the  advantages  afforded  by  hospital 
instruction  is  a  failure,  and  no  one  can  exjDect  to  attain 
eminence  as  a  teacher  or  as  an  author  in  medicine  or 
surgery  without  hospital  exj)erience  as  a  basis,  and  hos- 


OBJECTIONS  TO  HOSPITALS.  Q^ 

pital  practice  and  statistics  as  illustrating  and  verifyino- 
Lis  views. 

Since  tlie  establishment  of  tlie  training-school  for 
nurses  in  connection  with  St.  Thomas's  Ilosj^ital  hj 
MJss  Nightingale,  in  England,  sixteen  years  ago,  and 
in  this  country  of  the  school  for  nurses  in  connection 
with  Bellevue  Hospital,  New  York,  four  years  ago,  the 
great  advantages  of  hospital  instruction  are  recognized 
for  those  who  are  studying  nursing. 

There  is  a  popular  belief  that  doctors  experiment  on 
hospital-patients,  but  only  those  ignorant  of  the  facts  as 
they  are  at  the  present  time  can  have  such  an  idea.  In 
this  country,  at  least,  the  acts  of  a  physician  in  a  hospi- 
tal are  more  public  and  open  to  criticism  than  in  pri- 
vate practice.  What  he  does  is  done  in  the  presence 
of  several  and  often  many  persons  capable  of  under- 
standing whether  he  is  making  an  experiment,  and  if 
he  makes  a  mistake  it  is  known  to  all  the  hospital-staff; 
whereas,  in  private  practice,  if  he  has  the  confidence  of 
the  immediate  family,  on  account  of  their  inability  to 
understand,  he  can  venture  and  make  mistakes 'without 
discovery. 

In  the  founding  of  hospitals  the  question  of  their 
usefulness  to  medical  education  has  not  been  given  due 
consideration.  As  a  rule,  the  idea  of  rendering  imme- 
diate personal  relief  to  the  suffering  poor  is  the  first, 
and  in  many  cases  the  only,  acknowledged  object  aimed 
at  in  establish ino-  them. 

o 

The  objections  to  civil  hospitals,  as  now  stated,  may 
be  said  to  be — 

1.  As  institutions,  they  tend  to  weaken  the  family 
tie  by  separating  the  sick  from  their  homes  and  their 
relatives,  who  are  often  too  ready  to  relieve  themselves 

5 


66  RELATIONS  OF  HOSPITALS  TO  PAUPERISM. 

of  tLe  burden  of  tlie  sick  and  lielpless  of  tlieir  family. 
Besides,  wlien  one  or  more  of  a  family  are  removed, 
those  left  at  home  are  in  an  uncertain  state  of  mind,  and 
in  many  instances  in  an  unprotected  condition.  TLe 
husband  loses  the  good  influence  of  his  wife,  and  the 
wife  the  protection  of  her  husband; 

2.  The  inmates  of  pauper-hospitals  are  liable  to  come 
in  contact  with  bad  influences ;  familiarity  with  suffer- 
ing, unaccompanied  by  the  occupation  of  relieving  those 
who  are  suffering,  ends  in  hardening  the  sensibilities, 
especially  in  the  young. 

3.  Like  all  public  and  general  charities  without  the 
safeguard  that  personal  knowledge  affords,  hospitals 
tend  to  foster  idleness,  helplessness,  and  their  natural 
results,  pauperism  and  crime.  . 

4.  Hospitals,  when  badly  constnicted  or  badly  man- 
aged, are  liable  to  cause  hospital-diseases  among  the 
inmates  and  become  centres  of  infection,  thus  defeating 
the  very  object  they  are  intended  to  promote. 

On  the  other  hand,  the  arguments  in  favor  of  civil 
hospitals  are — 

1.  They  are  a  necessity  under  many  circumstances 
for  giving  shelter  to  the  sick  and  helpless  ;  and  are  sup- 
posed to  be  the  most  economical  method  of  providing 
for  the  sick  poor. 

2.  They  are  of  very  great  value  as  affording  oppor- 
tunity for  a  comparative  study  of  diseases,  and  for  giv- 
ing practical  instruction  in  the  science  of  medicine  and 
the  art  of  nursing,  to  the  greatest  advantage ;  thus,  by 
helping  directly  a  few  individuals,  indirectly  rendering 
a  service  of  incalculable  value  to  the  world. 

3.  During  contagious  epidemics  they  are  a  ready 
and  practical  means  of  providing  for  those  who  are  in- 


PROPOSED  PLAN  FOR   GOVERNING  CHARITY.        07 

fected,  and  by  their  isolation  preventing  the  spread  of 
disease. 

As  means  toward  checking  the  undesirable  multi- 
plication of  expensive  institutions,  to  prevent  hospitals 
from  breaking  up  or  interfering  with  the  family  tie,  and 
at  the  same  time  to  keep  them  from  engendering  pau- 
perism, we  suggest — 

1.  Do  all  that  can  be  done  to  enlighten  the  poor  to 
help  themselves,  and  to  avoid  the  causes  of  disease. 

2.  Give  indirect  help  by  imjiroving  the  condition  of 
the  homes  of  the  poor,  by  strict  laws  in  regard  to  the 
existing  condition,  and  the  building  of  all  dwelling- 
houses,  manufactories,  schools,  etc.,  etc.,  and  in  regard 
to  the  sale  of  food,  etc. 

3.  Limit  hospital  accommodations  to  those  who 
have  no  homes  and  to  those  who  cannot  be  assisted 
at  their  homes. 

It  is  doubtful  if  the  State  can  give  out-door  help, 
even  medical  help,  without  doing  more  harm  than 
good ;  it  can  only  be  done  wisely  by  establishing  a 
Bureau  of  Intelligence  for  the  supervision  of  charities 
in  connection  with  the  Police  Department,  with  officers 
at  each  police-station,  where  the  names  and  the  num- 
bers of  the  inmates  in  every  house  in  the  precinct  or 
district  would  be  known ;  and  where  a  record,  made 
from  personal  knowledge  of  all  individuals  receiving 
help,  as  to  their  cii'cumstances,  the  amount  of  aid 
given,  etc.,  would  be  kept.  As  far  as  possible,  all  help 
rendered  should  be  guided  by  this  personal  knowl- 
edge ;  and  it  should  be  obligatory  on  all  charitable 
institutions  and  associations  to  give  infonnation  of  all 
assistance  afforded  by  them  to  individuals  living  in  the 


68  RELATIONS  OF  HOSPITALS  TO  PAUPErdSM. 

district.     No  lielj)  should  be  allowed  to  go  unrecorded, 
except  tliat  giveu  by  a  j^rivate  individual  as  a  personal 

gift. 

Tlirougli  tliis  Intelligence  Bureau,  reliable  personal 
knowledge  of  every  applicant  for  hospital-relief  could 
be  obtained.  We  fully  appreciate  tlie  great  difficulty 
of  organizing  and  uniting  voluntary  charities  in  this 
country,  where  there  are  so  many  different  religious 
sects ;  but,  by  establishing  such  a  system  as  the  above, 
much  could  be  done  toward  distributing  helj)  where  it 
is  really  needed,  and  toward  preventing  indiscriminate 
charity  and  in  detecting  impostors. 

To  avoid  the  injurious  moral  effects  of  hosj^itals  on 
the  characters  of  the  inmates,  and  to  prevent  such  bad 
sanitary  conditions  in  hospitals  as  are  sure  to  result  in 
prolonged  cures,  and  often  in  the  generation  of  fatal 
hospital-diseases,  it  is  necessary  to  have  hospitals  con- 
structed and  managed  in  accordance  with  the  teachings 
of  social  and  sanitary  science.  The  rest  of  this  essay 
will  be  devoted  to  the  pur230se  of  showing  how  this 
can  best  be  done  in  so  far  as  sanitary  science  is  con- 
cerned. 


CHAPTER    III. 

OKGANIZATION   AXD    MANAGE^IEISTT. 

More  than  four-fifths  of  all  that  we  have  been  able 
to  find  written  on  hospitals  is  mainly  abont  their  con- 
struction. Since  the  appearance  of  Miss  Nightingale's 
books,  "  Notes  on  Hospitals  "  and  "  Notes  on  Nui^sing," 
many  articles  have  been  written  on  "  Hospital-Construc- 
tion "  and  there  have  been  endless  discussions  as  to  the 
best  plans  for  building  and  for  ventilating  them ;  but 
rarely  has  the  subject  of  organization  or  management 
been  treated  of.  Many  times  the  results  of  carelessness 
on  the  part  of  the  doctors ;  unwise  and  fraudulent  man- 
agement ;  poor,  untrained  nurses ;  bad  food ;  and  gener- 
al uncleanliness,  have  been  unjustly  attributed  to  faults 
in  the  plan  of  construction.  A  well-managed,  poorly- 
constructed  hospital  will  give  a  far  better  result  than  a 
finely-constructed  hosj^ital  with  bad  management. 

Tlie  Board  of  Managers  and  the  Medical  Boards. — 
In  this  country  we  find  our  civil  hospitals  organized  as 
follows :  The  governing  power  is  vested  in  a  board 
termed  the  trustees,  managers,  or  governors,  and  in  the 
case  of  a  State  or  municipal  institution  called  commis- 


70  ORGANIZATION  AND  MANAGEMENT. 

sioners.  The  members  of  these  boards  are  usually  busi- 
ness-men, wealthy  merchants,  bankers,  etc.  ISTow  and 
then  the  name  of  a  prominent  medical  man  will  be 
found  among  them,  but,  as  a  rule,  the  main  elements 
represented  in  these  boards  are  the  business  or  financial 
and  the  j)hilanthropic  elements;  while  in  the  State  in- 
stitutions politics  is  the  ruling  element.  Science  is 
rarely  represented  in  the  boards  of  managers. 

The  medical  board  is  generally  comj)osed  of  promi- 
nent medical  men  aj^pointed  by  the  trustees.  A  physi- 
cian of  eminence  can  easily  get  a  position,  but  not  in- 
frequently hospital  appointments  depend  more  upon  the 
influence  an  aj^plicant  can  bring  to  bear  upon  the  trus- 
tees than  on  his  merits. 

It  would  be  supposed  that  the  trustees  naturally 
are  guided  by  the  members  of  the  medical  board  in 
deciding  upon  the  plan  of  construction,  etc.,  when  new 
hospitals  are  undertaken;  but  often  the  j^lans  of  the 
buildings  have  all  been  adopted  before  there  is  a  medi- 
cal board ;  and  not  infrequently,  even  when  there  is  a 
medical  board,  the  whole  subject  of  construction  is  put 
into  the  hands  of  a  committee  of  the  board  of  trustees 
— a  system  which  is  apt  to  end  in  the  adoption  of  a  plan 
prepared  by  some  architect ;  the  result  being  a  grand, 
monumental,  architectural  building,  with  all  the  "  mod- 
ern improvements  "  in  it  so  as  to  enable  the  largest  pos- 
sible number  of  people  to  live  in  the  smallest  possible 
space. 

The  natural  tendency  of  the  architect's  efforts  is  to 
produce  an  imj)osing  and  pleasing  effect  as  far  as  may 
be  compatible  with  the  idea  of  making  the  most  of  a 
very  small  space  of  ground,  for  he  is  constantly  at  work 
devising  the  best  plan  to  build  houses  in  crowded  cities 


BOARDS  OF  MANAGERS  AXD  MEDICAL  BOARDS.      71 

where  every  foot  of  ground  must  be  made  use  of.  The 
fiiult  cannot  be  said  to  rest  altogether  on  the  shoulders 
of  the  trustees;  they,  no  doubt,  are  guided  by  the 
knowledge  they  have  on  the  subject,  and  it  must  be  a 
very  exceptional  case  where  any  other  than  conscien- 
tious, philanthropic  motives  would  influence  them.  But 
business-men  and  politicians  should  not  be  expected  to 
decide  questions  of  sanitary  science.  Nothing  in  their 
training  would  lead  one  to  suppose  that  they  had  the 
requisite  knowledge.  The  difficulty  is,  that  scientific 
men,  especially  physicians,  do  not  take  sufficient  inter- 
est in  such  matters.  Badly-constructed  hospitals  and 
dwelling-houses  will  be  built,  and  the  causes  of  disease 
will  continue  to  create  preventable  disease  just  so  long 
as  doctors  leave  these  matters  to  business-men  and  poli- 
ticians and  their  architects. 

For  many  years  medical  men  have  devoted  their 
enero-ies  to  discoverino;  remedies  with  which  to  cure 
disease.  Lately  they  have  been,  and  are  still,  studying 
the  results,  i.  e.,  the  j)athology  of  disease.  Very  lately 
the  study  of  the  causes,  i.  e.,  the  etiology  of  disease,  has 
attracted  much  attention ;  and  we  hope  that  soon  there 
will  be  a  more  general  and  direct  interest  shown  in  the 
endeavor  to  prevent  disease,  the  highest  function  of 
science  in  medicine.  At  present,  medical  men  are  too 
busy  curing  illness,  to  give  much  practical  consideration 
to  methods  of  prevention.  Suppose  the  trustees  who 
are  about  deciding  upon  a  plan  call  in  the  members  of 
the  medical  board  to  advise  them :  nine-tenths  of  the 
medical  men,  never  having  studied  or  even  seriously 
considered  the  subject  of  hospital-construction,  would 
be  indifferent,  or  incapable  of  giving  good  advice,  and 
the  few  who  understand  the  princij^les,  not  being  pre- 


72  OEGAmZATION  AND  MANAGEMENT, 

2:)ared  as  to  tlie  latest  views  in  construction,  and  being 
perhaps  too  busy  Avitli  their  own  private  affairs  to  be- 
stow that  time  and  sj)ecial  consideration  on  the  subject 
which  wouhl  enable  them  to  give  good  advice,  the 
trustees  and.  architects  are  left  to  themselves  to  erect 
a  badly-planned  hospital. 

In  New  York  City,  since  18G5,  the  close  of  the  war, 
six  new  hosj^itals  have  been  built — the  smallest  of  these, 
with  the  ground  it  stands  on,  costing  about  half  a  mill- 
ion dollars ;  and  three  of  the  six  nearly,  and  one  at  least 
quite,  a  million  dollars.  Only  one  of  these  new  hospi- 
tals can  claim  to  be  an  improvement  upon  a  hospital 
erected  in  Europe  just  fifty  years  ago  on  a  plan  pro- 
posed a  hundred  years  ago,  or  can  comj)are  favorably 
with  the  first  New  York  hospital,  that  was  destroyed 
by  fire  a  century  ago ;  and  only  this  one  of  the  six  has 
a  building  to  show  as  an  attempt  toward  fulfilling  the 
principles  which  should  be  adhered  to,  and  which  were 
taught  us  by  the  experience  of  the  late  war.  We  mean 
the  detached  surgical  pavilion  at  Roosevelt  Hospital. 

The  progress  in  the  construction  of  hospitals  can  be 
traced  to  scientific  and  medical  men,  aroused  to  a  sense 
of  duty  by  the  ravages  of  pestilence  or  war,  and  to 
their  iudifterence  can  with  justice  be  attributed  the 
fact  that  ex2:>ensive  buildings  are  erected  for  hosj^ital 
purjioses  to-day,  which  from  a  sanitary  standpoint 
would  only  be  creditable  to  the  middle  ages.  Some 
of  the  most  eminent  in  the  medical  profession  go  daily 
to  visit  and  treat  the  sick  poor  in  hospital-wards, 
where,  if  they  themselves  were  suffering  from  a  com- 
pound fracture,  or  even  an  amputated  finger,  they  could 
not  be  paid  to  remain  for  a  day,  on  account  of  the  dan- 
ger of  contracting  that  fatal  disease,  2">y9emia,  from  the 


BOARDS  OF  MANAGERS  AND  MEDICAL  BOARDS.     73 

atmos2:)liere  of  tlie  wards.  If  tlie  medical  board  is  not 
responsible  for  the  sanitary  condition  of  a  hospital,  who 
is  ?  The  trustees  have  never  studied  either  sanitary 
science  or  medicine;  they  accept  the  reports  of  the 
medical  board,  without  knowing  that  many  of  the 
deaths  in  their  institutions  are  due  to  disease  gener- 
ated by  the  bad  sanitary  condition  of  the  hospital. 
Examine  closely  the  public  reports  of  the  medical 
boards  of  hospitals,  and  see  how  rarely  they  give  any 
other  impression  than  that  everything  is  satisfactory, 
and  exactly  as  it  should  be.  Yet  the  statistics  in  some 
of  these  same  reports  will  show  a  death-rate  of  one  in 
every  seven  of  all  patients  admitted,  and  that  one  in 
every  fifteen  of  the  deaths  is  recorded  as  due  to  hos- 
pital-disease. 

It  is  obvious  that  such  a  condition  of  things  would 
not  be  allowed  to  continue  if  the  trustees  or  manao-ers 
imderstood  sanitary  science.  It  has  been  proposed  to 
give  the  medical  j)rofession  a  representation ;  but  we 
believe  that,  if  the  members  of  the  medical  boards  of 
hospitals  would  properly  inform  themselves,  and  exert 
their  influence  as  they  should  do  to  bring  about  im- 
provement, such  a  step  would  hardly  be  necessary. 
Since  they  do  not,  it  might  be  a  good  plan  to  have  the 
profession  represented  on  the  boards  of  managers,  for 
then  they  could  be  held  more  directly  responsible. 
But,  under  the  present  rules  and  by-laws  of  our  hospi- 
tals, there  are  certain  objections  to  the  practical  work- 
ing of  this  plan.  It  is  a  well-known  fact  that  every 
eminent  physician  has  his  set  of  favorites  about  him, 
who  would  get  the  appointments  of  honor.  If  the  medi- 
cal profession  is  to  be  represented  in  the  boards  of  mana- 
gers, then  we  must  have  a  diflerent  method  of  making 


74  ORGANIZATION  AND  MANAGEMENT. 

appointments  for  the  positions  of  attending  physicians 
and  surgeons ;  and,  in  fact,  a  change  in  this  respect  is 
at  the  present  time  very  much  needed,  particularly  in 
laro-e  cities  where  there  are  schools  of  medicine. 

o 

Tlie  Value  of  Hospital  Appointments. — The  posi- 
tion of  manager  or  trustee  to  a  hospital  is  seldom 
sought  after ;  men  of  means  and  of  social  standing 
are  usually  selected  and  urged  to  fill  the  position.  It 
is  true,  a  man  may  accept  the  position  to  gratify  vanity, 
but  he  would  hardly  seek  it  for  the  sake  of  remunera- 
tion, or  as  an  important  means  of  making  a  reputation 
and  acquiring  valuable  experience  in  his  business.  On 
the  other  hand,  an  occasional  request  is  made  by  hospi- 
tal-trustees to  be  allowed  to  use  the  names  of  eminent 
medical  men  as  consulting  physicians  or  surgeons ;  but, 
it  is  not  at  all  necessary  for  them  to  seek  doctors  of 
reputation  and  merit  to  fill  the  positions  of  attending 
physicians  and  surgeons  to  a  hospital.  Such  positions, 
varying  with  the  size  and  importance  of  the  hospital, 
give  a  physician,  with  average  ability,  a  chance  to  build 
up  a  reputation,  secure  a  remunerative  private  practice, 
and  gain  an  experience  valuable  on  account  of  the  very 
favorable  opportunity  for  studying  and  comparing  dis- 
ease which  nothing  but  a  hospital  could  furnish,  while 
the  vantage-ground  on  which  he  stands  enables  him  to 
secure  a  professorship)  which  a  better  teacher  could  not 
get,  because  he  could  not  give  clinical  lectures  in  hos- 
pital to  the  students. 

"  In  Dublin,"  says  the  Pliiladelpliia  Medical  Times^ 
"  large  premiums  are  paid  for  hospital  appointments. 
In  the  Jervis  Street  Hospital  five  hundred  pounds  ster- 
ling— three  hundred  to  the  foreman  incumbent  and  two 


VALUE  OF  HOSPITAL  APPOI^TMEN'TS.  75 

liundred  to  the  liospitals — is  said  to  be  tlie  customary 
sum." 

As  louo'  as  a  doctor  is  interested  in  medicine,  lie 
will  usually  retain  Ms  hospital  a2:)pointment ;  if  he  is  a 
teacher  or  professor,  the  position  is  essential,  to  enable 
him  to  give  clinical  lectures.  Unless  a  physician  holds 
such  a  place,  where  he  can  make  the  acquaintance  of  and 
teach  the  younger  men  of  the  profession  his  views,  it 
will  be  a  difficult  matter  for  him  to  become  a  consult- 
ing physician,  which  is  an  enviable  position  for  a  physi- 
cian, especially  when  his  physical  strength  does  not  per- 
mit him  to  endure  the  active  life  of  a  j)ractitioner. 

Such  is  the  value  of  a  place  on  a  medical  board  that 
many  physicians  are  not  satisfied  with  holding  one  hos- 
pital appointment,  but  take  all  they  can  get ;  and  phy- 
sicians with  large  private  practice  will  be  found  holding 
two,  three,  four,  and  even  more  positions  as  visiting 
physicians  or  surgeons  to  different  hospitals. 

For  more  reasons  than  one,  it  is  wrong  for  one  phy- 
sician to  hold  two  or  three  hospital  apj)ointments  at  the 
same  time.  If  he  has  a  private  practice  to  attend  to  be- 
sides pre^^aring  and  delivering  two  or  more  lectures 
every  week,  it  is  utterly  impossible  for  him  to  visit 
once  every  day  his  hospital-patients  and  do  his  duty 
toward  them.  Necessarily  much  of  his  work  falls  on 
the  house-staff,  and  the  patients  must  be  satisfied  with 
seeing  the  attending  doctor  pass  hurriedly  through  the 
wards,  stopj^ing  here  and  there  to  examine  a  case  be- 
longing to  a  class  which  at  the  time  he  is  especially  in- 
terested in,  or  perhaps  an  interesting  case  which  he  is 
going  to  bring  before  the  students  at  his  next  lecture. 
For  one  to  monopolize  so  many  positions  is  an  injustice 
to  the  rest  of  the  profession.     It  may  be  from  a  sense 


Y6  ORGANIZATION  AND  MANAGEMENT. 

of  duty,  a  genuine  spirit  of  charity,  that  eminent  physi- 
cians give  their  valuable  time  to  the  sick  poor  in  hospi- 
tals,' but  it  cannot  be  said  to  be  charitable  toward  the 
rest  of  the  profession  for  them  to  hold  at  the  same  time 
several  very  desirable  positions  which,  if  they  are  not 
worth  anything  to  tliem,  would  be  of  great  value  to 
others. 

If  the  trustees  or  managers  of  our  hospitals  would 
make  it  a  i)art  of  the  constitution  or  by-laws  of  the 
hospitals  under  their  control  that  no  physician  or  sur- 
geon could  hold  the  position  of  attending  or  visiting 
j^hysician  or  surgeon  to  the  hospital,  and  at  the  same 
time  hold  a  similar  position  in  some  other  hospital,  they 
would  do  an  act  beneficial  to  the  patients,  as  well  as 
one  of  justice  toward  the  medical  profession. 

Besides  the  above  restrictions,  and  for  exactly  the 
same  reasons,  it  would  be  well  to  limit  the  length  of 
time  during  which  any  one  could  hold  the  position  of 
attending  physician  or  sui^geon.  Let  the  term  be  ten 
or  fifteen  years,  so  as  to  give  each  one  a  chance  to  re- 
ceive the  full  benefits,  and  time  sufficient  to  develop 
what  talent  he  has  in  him.  Even  though  it  be  a  work 
of  charity,  it  is  hardly  fair  that  one  person  should  con- 
tinue to  do  it,  long  after  it  has  enabled  him  to  reach 
the  highest  position  to  which  his  ability  entitles  him, 
and  to  the  exclusion  of  others  from  a  position  without 
the  advantages  of  w^hich  it  is  difficult  for  them  to 
make  use  of,  or  even  make  known,  what  ability  they 
may  possess. 

To  every  fifty  patients,  or  every  two  wards,  there 
should  be  a  visiting  doctor  and  one  assistant  visiting 
doctor  on  duty,  and  both  of  these  should  visit  the 
wards  once  every  day.     The  number  of  visiting  doctors 


INFLUENCE  OF  WOMEN  IN  HOSPITALS.  77 

could  be  increased  by  having  a  given  season  during 
wliicli  tliey  would  be  on  duty,  altei'nating  every  four  or 
six  months  with  others  of  the  medical  board.  To  the 
same  number  of  patients  there  should  be  three  resident 
doctors.  {See  Relation  of  the  Medical  School  to  the 
Hospital,  in  a  subsequent  chapter.) 

The  Injiuence  of  Women  in  Hospitals. — Besides  the 
need  of  scientific  representation  in  the  boards  of  mana- 
gers, the  want  of  another  very  essential  influence  is 
noticeable  in  hospital  management. 

Into  the  housekeeping,  the  laundry,  kitchen,  and 
nursing  service  of  hospitals,  abuses  often  creep  and 
become  permanent  fixtures,  because  the  inspecting  com- 
mittees, all  composed  of  men,  do  not  detect  them.  The 
wards,  etc.,  may  present  a  cleanly  and  orderly  appear- 
ance, while  many  abuses  lie  concealed,  which  only  an 
expert  in  housekeeping  would  discover.  Prominent 
business-men  are  not  experts  in  housekeeping,  nor  is  it 
possible  for  men  to  equal  women  in  this  department, 
not  only  because  they  have  not  had  the  experience,  but 
because  Nature  does  not  give  them  the  gift. 

Admitting  that  men  can  supervise  the  housekeeping 
and  nursing  of  a  hospital  and  secure  their  being  eco- 
nomically done  and  to  the  eyes  of  an  inspector  well 
done,  still,  as  a  rule,  institutions  so  governed  will  be 
wanting  in  one  of  the  most  desirable  and  essential  par- 
ticulars, namely,  that  gentle  and  refining  moral  influ- 
ence which  is  seldom  found  outside  of  the  house  ^a^t 
in  order  by  a  woman.  Under  men  it  might  work  as 
smoothly  and  noiselessly  as  a  Corliss  engine,  but  the 
good  influence  of  human  sympathy  would  be  wanting, 
and  the  subordinates  would  do  their  work  for  what 


78  ORGANIZATION  AND  MANAGEMENT. 

they  could  "  make "  out  of  it,  and  in  time  would  Ije- 
come  hardened  and  in  some  instances  cruel;  their  high- 
est aim  and  effort  being  to  please  the  superintendent  by 
making  a  sufficiently  good  appearance  to  satisfy  the  vis- 
iting committee.  The  case  is  im23roved  where  female 
subordinates  of  good  character  are  emj^loyed,  but  the  in- 
fluence to  be  effectual  must  come  from  the  highest  power. 
It  is  the  management,  whatever  that  may  be,  which  gives 
the  tone  to  the  institution.  Strict  order  and  disci23line 
will,  or  rather  must,  suffice  in  the  housekeeping  depart- 
ment of  a  man-of-war  and  of  barracks ;  but  in  a  hospi- 
tal, to  these,  sympathy  and  kindness  should  be  added. 
The  nearer  a  hospital  resembles  what  we  understand  as 
expressed  by  the  word  liome^  the  better  it  is ;  and,  to 
approach  this,  woman's  influence  must  be  felt,  from  the 
board  of  manasrers  down  to  the  coal-heaver. 

How  is  it  practicable  to  introduce  this  influence 
into  the  administration  of  hospitals  ?  A  separate 
board,  composed  entirely  of  ladies,  to  assist  in  man- 
aging, has  been  tried.  This  plan  seems  to  work  very 
well  as  long  as  the  hospital  is  comparatively  small ; 
but,  unless  the  different  members  of  all  the  boards  are 
well  known  to  each  other,  misunderstandings  are  sure 
to  arise,  it  being  difficult  to  keep  up  harmony  and 
unity  of  action  betw^een  the  board  of  governors,  the 
board  of  lady  managers,  and  the  medical  board.  To 
obviate  this  complication,  it  has  been  suggested  that 
there  should  be  a  limited  number  of  lady  members 
appointed  on  the  board  of  governors  instead  of  a  sepa- 
rate board  of  lady  managers,  it  being  understood  that 
the  special  duty  of  the  ladies  would  be  to  supervise  and 
direct  the  organization  and  administration  of  the  house- 
keeping and  nursing  departments. 


INFLUENCE  OF   WOMEN  IN  UOSPITALS.  79 

Five  years  ago  tlie  "  State  Charities  Aid  Associa- 
tion "  was  organized.  The  Association  is  "  composed 
of  ladies  and  gentlemen  who  propose  to  establish  local 
visiting  committees  for  the  almshouses,  hospitals,  and 
other  public  institutions  of  charity  throughout  the  city 
and  State  of  New  York."  The  objects  are — "  1.  To 
promote  an  active  public  interest  in  the  New  York 
State  Institutions  of  Public  Charities,  with  a  view  to 
the  physical,  mental,  and  moral  unjn'ovement  of  their 
pauper  inmates.  2.  To  make  the  present  pauper  sys- 
tem more  efficient,  and  to  bring  about  such  reforms  in 
it  as  may  be  in  accordance  with  the  most  enlightened 
views  of  Christianity,  science,  and  philanthropy." 

For  five  years  the  Association  has  been  thoroughly 
organized  and  earnestly  at  work,  and  much  good  has 
been  accomplished.  The  membership  now  numbers 
about  twelve  hundred.  The  ladies'  committees  regu- 
larly visit  and  inspect  the  hospitals  and  other  public 
institutions.  They  have  no  direct  authority,  but  indi- 
rectly they  have  great  influence  on  the  management 
and  administration  of  these  institutions.  They  have 
succeeded  in  introducing  trained  nursing  by  establish- 
ing: a  "  Trainings-School  for  Nurses  "  in  connection  with 
Bellevue  Hospital.  This  school,  organized  after  the 
system  inaugurated  by  Miss  Nightingale  in  England, 
has  proved  to  be  a  great  success.  The  superintendent 
of  the  school  is  a  lady,  both  by  birth  and  education, 
and  several  of  the  fifty  nurses  and  pupils,  now  at  work 
in  the  wards  of  the  hospital,  are  refined  and  educated 
women,  who  have  taken  up  the  work,  not  from  neces- 
sity, but  choice.  The  introduction  of  these  ladies  into 
the  wards  of  this  pau]3er-hospital  has  not  only  changed 
completely  the  moral  atmosphere  of  the  place,  and  re- 


80  ORGANIZATION  AND  MANAGEMENT. 

cluced  tlie  cleatli-rate,  but  promises  to  revolutionize  "both 
hosj^ital  and  private  nursing  tliroughout  the  country.  ., 
Already  several  scliools  have  been  organized  in  other  * 
cities  and  are  v^orking  successfully.  By  means  of  these 
training-schools  for  nurses,  the  influence  of  women  can 
be  successfully  introduced  into  hospitals.  To  every 
fifty  patients  there  should  be  not  less  than  ten  trained 
nurses  and  student-nurses.  (^See  Relations  of  the 
Training-School  for  Nurses  to  Hospitals,  in  a  subse- 
quent chapter.) 

Both  breathing  and  eating  are  essential  to  sustain 
life ;  but,  since  breathing  must  be  kept  up  at  all  times, 
we  may  say  that  breathing  is  of  more  importance  than 
eating.  In  the  same  sense  ^ve  may  say  that  nursing, 
which  should  be  continuous,  is  of  more  imj^ortance  to 
the  sick  than  medical  attendance. 

The  Siqyerintendent. — The  superintendent  or  execu- 
tive officer  of  hospitals  in  this  country  is  appointed  by 
the  board  of  managers,  and  to  them  he  is  alone  resjoon- 
sible.  In  some  cases  the  superintendent  is  a  medical 
man,  but  not  infrequently  he  is  simply  the  business 
ao-ent  of  the  trustees,  and  makes  it  his  aim  to  maintain 
as  good  an  appearance  of  things  as  possible,  and  to 
please  the  trustees  by  keeping  down  the  exj)ense,  with- 
out much  knowledge  of,  or  much  regard  for,  the  welfare 
of  the  patients. 

In  every  hospital  there  are  three  legitimate  inter- 
ests ; 

1.  Charity,  or  the  humanitarian  interest,  which  seeks 
to  make  the  hospital  serve  the  welfare  of  the  j^atients ; 
the  motive  being  to  have  that  done  which  will  bring 
immediate  personal  good. 


THE  SUPERINTENDENT.  81 

2.  Learning,  or  tlie  scientific  interest,  wliicli  would 
use  tlie  hospital  for  the  pui'pose  of  studying  and  teach- 
ing the  science  of  medicine ;  the  motive  being  to  have 
that  done  which  in  the  future  will  do  good  to  all  man- 
kind. 

3.  The  material  or  economic  interest,  which  would 
limit  the  expenses  of  the  hospital ;  the  motive  being  to 
make  the  wisest  use  of  the  funds.  The  guardians  of 
the  first  and  the  third  are  the  trustees,  assisted  by  the 
nurses,  medical  men,  and  employes.  The  guardians  of 
the  second  are  the  attending  medical  staff,  assisted  by 
the  house-staff,  nurses,  and  employes.  These  three  in- 
terests, in  a  properly-conducted  hospital,  should  not  be 
conflicting ;  but  there  is  a  fourth  interest  that  often 
sho^vs  itself  in  hospitals — namely,  selfishness,  or  the  in- 
terest of  individuals,  who  strive  to  use  the  hospital 
for  the  purpose  of  adding  to  their  profits  or  their  repu- 
tation. It  is  this  selfishness  of  individuals  which  inter- 
feres with  the  true  interests  of  the  hosj^ital,  and  in  most 
cases  is  the  real  originating  cause  of  serious  quarrels 
between  the  different  parties  representing  them.  Be- 
sides, through  the  want  of  comprehensive  ap23reciation, 
and  the  natural  tendency  of  individuals  to  become  par- 
tisans, and  to  see  things  from  one  standpoint,  and 
through  personal  misunderstanding  and  enmity,  the 
representatives  of  the  true  interests  of  the  hospital 
not  infrequently  become  antagonistic. 

The  2)osition  of  the  suj^erintendent,  especially  in  a 
large  hospital,  to  Avhich  is  attached  a  medical  school,  is 
one  of  great  importance.  The  superintendent  should 
be,  if  not  a  Christian  man,  at  least  one  educated  in  and 
guided  by  moral  laws,  otherwise  he  would  not  appre- 
ciate the  humanitarian  interests  ;  he  should  be  a  person 
G 


82  ORGANIZATION  AND  MANAGEMENT. 

educated  in  medicine  and  guided  by  tlie  laws  of  liealtli, 
otherwise  lie  would  not  aj^preciate  the  scientific  inter- 
ests ;  and  he  should  be  a  person  who  understands  and 
is  guided  by  the  laws  of  economy,  otherwise  he  would 
not  api^reciate  the  material  interests  of  the  hospital. 
Besides,  he  must  be  a  jjerson  of  executive  ability  and 
sound  j)ractical  judgment,  for  it  will  be  his  duty  to 
■  supervise  and  direct  the  employes,  and  to  decide  and 
adjust  the  numerous  minor  differences  of  all  these  inter- 
ests. 

Suj^posing  the  superintendent  to  be  a  man  possess- 
ing a  knowledge  of  and  comprehensively  appreciating 
the  laws  of  morals,  health,  and  economy,  and  having 
executive  ability  and  practical  judgment,  what  should 
be  his  position,  and  his  relations  with  the  trustees  and 
the  attending  medical  staff  ? 

The  trustees  are  the  manao:ers,  the  controllino;  board 
of  the  hospital.  They  should  decide  upon  all  the  rules 
and  regulations.  By  them  all  the  duties  and  powers 
of  the  attending  medical  men  and  the  superintendent 
should  be  defined  and  decided.  They  should  reserve 
the  right  of  revoking  all  rules  and  regulations  defining 
the  duties  and  powers  of  every  one  connected  with  the 
hospital. 

The  superintendent  should  rank  in  ]30sition  with 
the  attending  physicians  and  surgeons,  and  have  a  seat 
at  the  meetings  of  the  medical  board,  so  as  to  be  in- 
formed on  all  questions  coming  before  them,  and  he 
should  have  a  seat  at  the  meetings  of  the  executive 
committee  of  both  the  board  of  trustees  and  the  medical 
board.  All  medical  questions  should  be  brought  be- 
fore the  medical  board  for  consideration,  and  for  them 
to  report  upon,  and  their  rej^orts  should  be  taken  by 


THE  SUPEEI2TTEXDEXT.  83 

one  of  tlieir  number,  witli  tlie  superintendent,  before 
the  board  of  trustees  for  final  decision. 

All  questions  arising,  wliicli  are  not  covered  by  tlie 
rules  and  reo;ulations,  sliould,  if  immediate  action  is  re- 
quired,  be  decided  by  the  superintendent,  whose  deci- 
sion should  hold  good  till  the  matter  is  finally  decided 
by  the  board  of  trustees. 

Once  every  month,  just  after  the  meeting  of  one  of 
the  boards,  there  should  be  a  joint  meeting  of  the  board 
of  trustees  or  their  executive  committee  with  the  mem- 
bers of  the  medical  board,  at  which  certain  subjects 
should  be  discussed.  One  object  of  this  joint  monthly 
meetino;  would  be  to  brino;  the  members  of  the  two 
boards  into  personal  acquaintance,  and  thus  prevent 
rumors  and  insinuations  about  individual  members 
from  havino;  undue  influence.  It  is  not  an  uncommon 
thine:,  in  lars-e  cities,  to  find  trustees  and  the  attendins: 
medical  men  of  the  same  hospital,  personally  strangers, 
knowing  nothing  of  each  other,  except  by  reputation 
and  report. 

To  be  educated  as  a  physician  implies  that  a  man 
has  studied  the  subject  on  which  sanitary  science  is 
based ;  but  it  is  rare  to  find  a  doctor  who  is  a  sani- 
tarian ;  in  fact,  many  doctors  seem  never  to  have  dii'ect- 
ly  considered  the  su1)ject.  The  superintendent,  there- 
fore, besides  being  a  medical  man,  or  one  educated  as 
such,  should  be  a  good  sanitarian,  and  one  who  has 
given  special  study  to  hospital-construction,  and  who 
has  some  knowledfre  of  mechanics  and  ci\"il  eno-ineer- 
ing.  It  is  useless  to  depend  upon  a  committee  of  in- 
spection appointed  from  the  members  of  the  medical 
board,  whose  duty  it  would  be  to  sujoervise  the  sani- 
tary condition  of  the  hospital.     They  are  men  too  bu>y 


84  OBGANIZATIOX  AND  MAFAGEMEXT. 

to  attend  to  tlie  work,  even  in  a  routine  way,  and  they 
never  tliink  of  studying  up  sanitary  subjects.  Tlie 
duty  of  tlie  superintendent  would  be  the  constant  per- 
sonal suj)ervision  of  tlie  liosj^ital,  esj^ecially  in  regard 
to  its  hygienic  and  sanitary  condition.  In  a  large  hos- 
pital, under  the  superintendent  there  should  be  a  stew- 
ard, whose  duty  it  would  be  to  take  charge  of  the  ac- 
counts and  supj^lies  of  the  hospital;  a  clerk,  to  have 
charsce  of  th^  recordino;  of  admissions  and  dischars-e  of 
patients,  and  the  books  in  the  office ;  a  warden,  to  w^atch 
the  male  attendants,  and  to  have  charge  of  the  police 
of  the  hospital ;  and  a  lady  suj^erintendent  of  the  nurs- 
ing, diet,  and  cleansing,  of  the  hospital. 

An  important  duty  of  the  superintendent  would  be 
to  carefully  supervise  the  construction  and  repairing  of 
all  buildings.  Let  the  plans  be  never  so  well  prepared, 
numerous  questions  will  arise,  which  can  only  be  de- 
cided by  a  superintendent  of  the  qualities  described 
above.  Unless  such  a  person  is  on  the  spot  while  the 
work  is  going  on,  many  opportunities  will  be  lost  for 
makins:  minor  and  sometimes  radical  and  essential 
changes  in  the  carrying  out  of  the  j^lans.  On  this 
account,  it  will  be  of  the  greatest  importance  to  select 
the  superintendent  before  the  work  of  building  the  hos- 
pital is  commenced. 

The  superintendent  must  be  a  man  of  position  and 
ability,  and  one  who  can  be  trusted  with  authority ; 
otherwise  he  will  be  made  a  tool  of,  and  will  serve  the 
interests  of  some  individual  or  clique,  instead  of  those 
of  the  hospital.  Any  attempt  on  the  part  of  the  tms- 
tees  or  others  to  employ  a  superintendent  of  inferior 
capacity,  and  to  depend  on  supervising  the  hospital 
from  the  outside,  will  result  in  failure. 


TUE  SUPERINTENDENT.  85 

For  tlie  details  of  internal  management  we  refer  our 
readers  to  tlie  "  Hand-Book  for  Hospital  Visitors,"  docu- 
ment  No.  13  of  tlie  State  Charities  Aid  Association.  It 
is  a  book  of  one  hundred  and  fifty  pages,  very  complete 
and  practical,  and  supplies  a  want  in  hospital  literature. 
It  will  rank  with  Miss  Nightingale's  "  Notes  on  Nurs- 
ing," and'  is  more  direct  and  better  adapted  for  use  in 
hospitals. 


CHAPTER    IV. 

THE   COISTSTRUCTIOjST    OF   A    CIVIL    nOSPITAL. 

"VVe  have  said  that  a  poorly-constructed  hospital 
well  managed  will  give  better  results  than  one  well 
constructed  but  badly  managed ;  now  we  add,  that  a 
properly-constructed  hospital  properly  managed  mil 
give  still  better  vital  results  and  at  the  same  time  can 
be  managed  with  greater  ease  and  economy. 

The  conservative  and,  in  some  cases,  more  or  less  in- 
terested hospital  authorities,  who  for  years  23ast  have 
opposed  a  change  in  the  construction  of  hospitals,  now 
claim  that  with  intelligent  and  well-trained  nurses,  to- 
gether with  the  adoption  of  Lister's  antiseptic  method 
of  dressing  wounds,  pyaemia  and  other  hospital-dis- 
eases will  no  longer  occur,  and  therefore  the  necessity 
for  replacing  the  old,  massive,  many-storied  hospitals 
with  those  of  modern  construction  no  lono;er  exists.  It 
would  be  well  for  those  who  so  strongly  resist  any  pro- 
posed change  of  the  old  buildings,  to  study  the  history 
of  training-schools  for  nurses,  before  they  undertake  to 
use  the  good  influence  of  trained  nurses  as  an  argument 
in  opposing  further  improvement,  for  they  will  discover 
that  the  advocates  of  improved  plans  of  construction 
are  the  very  founders  of  these  schools,  and  that  it  is 


EXCUSES  FOB  FAULTS  OF  CONSTRUCTION.  87 

tliroiii>;li  tlieir  efforts  tliat  trained  niirsiiiir  lias  Leen 
introduced.  We  know  full  well  tliat  trained  nursino- 
and  good  management  w^ill  modify  bad  hospital  in- 
fluences ;  and  that,  if  the  antiseptic  method  of  dressing 
^rounds  after  Mr.  Lister's  teachings  is  eflSciently  carried 
out  in  all  its  details,  pyaemia  will  occur  less  frequently 
and  the  death-rate  in  hospitals  will  thereby  be  lessened : 
still,  foul  air  will  continue  to  do  harm  by  prolonging 
convalescence  and  reducino;  the  2:eneral  health  of 
patients,  thus  extending  their  stay  in  hospital,  and 
rendering  them  more  liable  to  a  relapse,  and  always 
depriving  the  patients  of  a  certain  amount  of  power 
to  resist  successfully  disease.  Every  one  knows  that 
a  man  may  not  starve  to  death  on  poor  food,  but  that 
good  food  is  much  better,  for  it  renders  him  less  likely 
to  contract  disease,  and  gives  him  strength  to  resist  its 
flital  tendency.     Exactly  the  same  is  true  of  air. 

Good  management,  trained  nursing,  and  im23roved 
medical  and  surgical  skill,  may  reduce  the  death-rate, 
and  to  a  great  extent  counteract  the  evil  effects  of  bad 
air;  but  these  are  no  justification  for  the  existence  of 
poorly-planned  hospitals.  Saying  and  even  proving, 
were  that  possible,  that  pyaemia  and  other  diseases 
caused  by  foul  air  occur  in  private  practice  equally  as 
often  as  in  hospitals,  should  not  prevent  us  from  bring- 
ing about  a  change  in  hospital-building  vrhich  should 
rid  us  of  these  evils;  from  a  sanitary  standpoint  it 
would  be  absurd  to  assume,  as  this  comj^arison  re- 
quires us  to  do,  that  our  private  houses  are  proj^erly 
constructed. 

If  a  ward  is  carefully  sealed  up  and  filled  with 
steam,  and  several  bushels  of  chloride  of  sodium  and 
the  black  oxide  of  manganese  are  mixed  and  spread      ^ 


88  CONSTRUCTION  OF  A   CIVIL  HOSPITAL. 

out  in  lead  joaus  placed  on  tlie  floor,  and  if  tlien  several 
carboys  of  sulj^liuric  acid  are  poured  on,  tlius  generat- 
ing several  tons  of  chlorine  gas,  and  tlie  ward  is  kept 
closed  for  twenty-four  Lours,  undoubtedly  that  ward 
may  be  said  to  be  thoroughly  disinfected,  or  at  least 
the  disease-germs  are  rendered  inert  for  a  time.  But 
the  very  fact  that  the  ward  lias  become  infected  to 
such  an  extent  as  to  render  this  process  necessary  is 
the  strongest  possible  argument  against  the  fitness  of 
the  ward  for  the  inhabitation  of  the  sick. 

Admitting  that  disinfection  not  only  renders  inert 
but  actually  destroys  the  disease-germs,  as  patients  can- 
not live  in  an  atmosj^here  of  chlorine  gas,  nor  in  that  of 
any  other  disinfectant  j)ossessing  sufficient  power  to 
even  render  the  germs  inert,  therefore  disinfection  is 
only  a  palliative,  and  not  a  preventive  measure.  "  An 
ounce  of  prevention  is  worth  a  pound  of  cure"  is  a 
j)roverb  equally  as  ap|)licable  to  an  infected  hospital  as 
it  is  to  disease  in  man.  Eemoval  of  the  cause  of  disease 
is  the  first  law  in  sanitary  science,  and  the  more  nearly 
this  law  is  followed  in  hosj^ital-construction  the  better 
the  results  will  be. 

We  will  assume  that  it  has  been  decided  to  estab- 
lish a  general  hospital,  say,  of  foui*  hundred  beds  for 
the  purpose : 

1.  Of  giving  to  the  sick  poor  better  care  and  atten- 
tion than  they  can  otherwise  command  while  sick. 

2.  To  afibrd  the  medical  profession  of  the  commu- 
nity an  oppoiliunity  of  studying  and  teaching  the  science 
of  medicine,  to  the  fullest  extent  that  this  .can  be  done 
without  in  any  way  interfering  with  the  welfare  of  the 
patients. 

3.  To  afford  those  desirous  of  becoming  nurses  the 


LOCATIOX.  89 

opportunity  of  being  taught  and  trained  as  nurses  to 
the  very  best  advantage. 

All  contaQ-ious  and  infectious  cases  are  to  be  ex- 
eluded  as  being  dangerous  to  others.  JS^o  maternity 
wards  are  to  be  connected  with  the  hospital,  on  account 
of  the  great  danger  to  lying-in  women  of  their  contract- 
ing puerperal  fever  when  treated  in  wards  connected 
with  a  general  hospital. 

The  hospital  is  for  general  medical  and  surgical  dis- 
eases, and  such  special  diseases  as  are  in  no  way  dan- 
gerous to  others,  and  as  can  be  conveniently  treated  in 
connection  with  such  an  institution.  There  is  to  be  a 
limited  number  of  beds  for  the  use  of  strangers,  and 
others  Avithout  homes,  willing  to  pay  for  hospital  treat- 
ment. 

Location. — ^The  first  thino;  to  be  decided  is  the  loca- 
tion.  In  a  small  city  or  to^Ti  there  is  no  question  as 
to  whether  the  hospital  should  be  placed  in  the  midst 
of  the  town,  or  outside  in  spacious  grounds;  but  in 
large  cities  many  objections  are  made  to  the  hospital 
being  removed  from  the  centre  of  population.  It  is 
claimed  that  the  sick  cannot  be  safely  transported,  and 
on  that  account  the  hospital  must  be  in  town.  The 
real  difficulty  is  that,  if  the  hospital  is  out  of  town,  the 
managers  and  attending  physicians  and  surgeons  are  in- 
convenienced, and  in  the  case  of  the  doctors  it  would  be 
hardly  possible  for  those  in  full  practice  to  leave  town 
every  day.  Then,  too,  the  medical  schools  are  in  town, 
and,  if  the  hospitals  are  out  of  town,  clinical  instruction 
would  be  attended  with  difficulty. 

In  answer  to  this  we  would  say  that  in  large  cities 
where  the  streets  average  not  more  than  fifty  or  sixty 


90  COKSTRUCTION  OF  A   CIVIL  HOSPITAL. 

feet  in  width,  unless  a  hospital  can  be  in  the  centre  of  a 
large  park,  it  should  be  placed  out  of  town  for  the  fol- 
io win  sc  reasons : 

So  as  to  give  the  patients  the  advantage  of  pure 
air — doctors  send  their  private  patients  out  of  town 
to  get  the  benefits  of  pui-e  air ;  to  free  the  hospital  and 
its  grounds  from  surrounding  obstructions  to  the  free 
circulation  of  the  outside  air ;  to  remove  the  hospital 
from  sources  that  render  the  air  impure,  such  as  large 
seivers,  manufactories,  the  filth,  dirt,  and  dust,  of  the 
city  streets  and  houses,  etc. 

On  the  ground  of  economy ;  the  land  is  cheaper,  and 
this  permits  the  erection  of  cheap  one-story  buildings  in 
place  of  costly,  many-storied  structures. 

As  to  the  question  of  transportation,  the  improved 
ambulances  and  other  means  of  conveyance  practically 
do  away  with  the  difiiculty  when  combined  with  a  sys- 
tem of  small  reception-hospitals,  one  or  more  as  the  cir- 
cumstances demand,  of  a  few  beds  each,  where  emer- 
gency-cases could  be  received  and  treated  until  able  to 
be  carried  to  the  general  hospital. 

As  to  the  inconvenience  to  the  managers,  if  they 
are  working  for  the  welfare  of  the  patients,  then  they 
should  do  their  duty,  or  give  way  to  others  who  would. 
The  attending  doctors  who  are  expected  to  treat  the 
cases  should  not  be  men  with  very  large  private  prac- 
tice ;  whether  the  hospital  is  in  or  out  of  town,  they 
cannot  well  spare  the  time  to  do  the  every-day  work. 
Such  men,  if  they  will  hold  the  hospital  positions, 
should  have  assistants  to  do  the  work  that  they  have 
not  the  time  to  do. 

As  to  the  medical  schools,  the  question  is  of  more 
importance;    but,  under  a   better  system,  where   the 


PREPARATION  OF  TEE  GROUNDS.  91 

clinical  instruction  is  confined  to  tlie  more  advanced 
students,  tlie  difficulty  would  not  be  so  great. 

Whether  in  or  out  of  town,  tlie  site  of  the  hospital 
should  be  selected  as  having  the  best  natural  advan- 
tages; and  these  are:  a  porous  and  well-drained  soil 
and  subsoil,  with  southern  exposure,  and  with  jorotec- 
tion,  in  our  climate,  fi'om  the  north  and  east  winds,  but 
in  no  way  affected  by  receiving  the  di'ainage  of  higher 
ground ;  lastly,  sufficiently  removed  from  swamps,  ponds^ 
or  any  source  of  malarial  emanations. 

Prejparation  of  the  Grounds. — Unless  the  soil  is 
remarkably  well  drained  by  nature,  deep  subsoil  drains 
should  be  laid  with  great  care  so  as  not  to  interfere 
with  the  foundations  of  the  different  buildings,  but  at 
the  same  time  take  every  advantage  of  the  natural  lay 
of  the  grounds.  AVhether  such  drainage  of  the  ground 
is  necessary  or  not,  on  account  of  the  nature  of  the 
soil,  it  will  be  an  advantage,  if  j^roperly  done,  for 
porous  earth  (and  well-drained  ground  is  porous)  is 
one  of  the  very  best  disinfectants,  and  naturally  ab- 
sorbs noxious  gases,  and  thus  tends  to  purify  the  air 
around  the  hospital. 

In  large  cities  sometimes  it  becomes  a  necessity  to 
erect  one  or  more  small  reception-hosj)itals  in  crowded 
districts ;  but  not  infrequently  large  hospitals  will  be 
built  in  locations  where  they  should  not  be,  and  on 
badly-drained  soils.  To  modify  the  inevitable  evil  of 
insufficient  and  impure  air,  when  a  hospital  is  built  in  a 
crowded  district  suiTounded  by  blocks  of  houses,  etc., 
which  obstruct  the  free  circulation,  an  additional  space 
should  be  allowed,  both  within  and  without  the  wards, 
to  each  patient ;  and  if  the  soil  is  damp,  besides  the 


92  CO^fSTEVCTIOK  OF  A    CIVIL  HOSPITAL. 

effort  to  drain  it,  it  would  be  well  to  raise  tlie  wliole 
surface  by  adding  several  feet  of  suitable  earth,  and  by 
all  means  to  j^ut  tbe  wards  on  raised  foundations  and 
cover  tlie  surface  beneatli  tliem  witb  concrete  and  as- 
phalt, and  leave  the  space  open  to  tlie  sun  and  air. 

Character  of  tlie  Buildings. — The  site  being  select- 
ed, the  next  thing  to  do  is  to  determine  the  character 
of  the  buildings  to  be  placed  upon  it. 

More  than  a  hundred  years  ago  it  was  very  clearly 
shown  that  a  large  number  of  sick  people  should  never 
be  assembled  under  the  same  roof,  as  it  is  impossible  to 
supply  each  patient  with  the  requisite  amount  of  fresh 
air  on  account  of  the  large  quantities  of  poisonous  gas 
thrown  off  from  the  luno;s  and  emanatino:  from  the 
bodies,  the  wounds  and  excretions  of  the  patients,  and 
continually  infecting  the  air ;  that  in  a  large  building 
the  foul  air  of  one  part  could  not  be  prevented  from 
permeating  the  whole  structure — in  this  way  one 
infectious  case  beiuo;  liable  to  infect  all  the  inmates ; 
and  that  in  a  large  building  it  was  difficult  to  give  each 
patient  sufficient  sunlight.  To  obviate  these  difficulties 
it  was  decided — 1.  To  divide  a  large  hospital  into  a 
number  of  small  buildings  ;  2.  That  the  administrative 
offices,  the  apartments  of  the  officers  and  servants,  the 
stores,  drugs,  etc.,  should  be  in  a  separate  building 
from  those  containing  the  patients;  3.  That  the  sepa- 
rate buildings,  or  pavilions  containing  the  sich,  should 
each  contain  only  two  or  three  wards,  and  the  rooms  or 
wards  in  which  the  patients  were  to  be  treated  should 
have  a  limited  number  of  beds  in  them ;  4.  That  the 
wards  should  be  so  constructed  as  to  give  each  j^atient 
a  lai'ge  cubic  space  of  air,  and  by  means  of  opposite 


CLASSIFICATION-  ACCORDING  TO  DISEASE.  93 

windows,  etc.,  to  admit  of  easy  ventilation  and  plenty 
of  suuliglit;  5.  Tliat  eacli  ward  should  liave  certain 
necessary  accessory  or  service  rooms  connected  with 
it ;  6.  That  the  buildings  or  pavilions  containing  the 
patients  should  be  separated  some  distance  from  each 
other  and  all  other  buildings,  and  connected  with  the 
administrative  building  and  the  other  pavilions  by  a 
corridor  or  simple  inclosed  passage-way.* 

These  ])rinciples  were  plainly  and  definitely  given 
in  the  report  of  the  committee  appointed,  from  the  mem- 
bers of  the  French  Academy  of  Sciences,  to  decide  uj^on 
a  plan  for  rebuilding  the  IIotel-Dieu  as  early  as  1V86. 

Notwithstanding  the  fact  that  previous  to  1860, 
with  only  three  or  four  exceptions,  civil  hospitals  were 
not  constructed  in  accordance  with  the  above  princijoles, 
still,  since  the  completion  of  the  Lariboisiere  in  1854  on 
the  plan  proposed  by  the  French  Academy's  committee, 
the  above  ideas  have  been  in  the  main  accepted,  and  in 
most  of  the  hosj)itals  erected  after  1860  they  have  been 
carried  out  with  various  modifications,  while,  since  the 
apj^earance  of  Miss  Nightingale's  book,  the  "  pavilion 
plan  "  has  become  very  popular.  Accepting  the  above 
principles,  we  proceed  with  our  plan. 

Classification  of  the  Patients  according  to  tlieir 
Diseases. — We  do  not  accept  the  usual  custom  of  hav- 
ing one  j)lan  of  wards  for  all  the  patients  of  a  general 
hospital,  and,  since  the  character  of  the  ward  is  to 
depend  upon  the  class  of  diseases  to  be  treated  in  it, 
we  will  first  indicate  a  general  system  of  classification : 

^  "We  refer  our  readers  to  Miss  Nightingale's  book,  "  Notes  on  Hospi- 
tals." In  it  will  be  found  the  best  argument  in  favor  of  the  pavilion  plan 
and  against  the  old,  massive,  many-storied  hospital-buildings  now  in  use. 


94:  CONSTRUCTION^  OF  A    CIVIL  HOSPITAL. 

Class  L — ^Non-infected  cases  aucl  those  not  liable 
to  become  so  or  to  infect  others — as  rheumatism,  dis- 
eases of  the  heart,  liver,  kidneys,  etc. 

Class  II. — Non-infectious  cases  and  not  dangerous 
to  others,  but  liable  to  become  infected — as  slight 
wounds,  scalp-wounds,  with  slight  fracture  of  skull,  etc. 

Class  III. — ^Non-infectious,  but  liable  to  become  so, 
and  dangerous  at  all  times  to  others — as  sloughing 
wounds,  burns,  etc. 

Class  IV. — Infectious  and  contagious  cases — as  pyae- 
mia, septicaemia,  erysipelas,  gangrene,  etc. 

The  Ward. — Shall  each  ward  be  in  a  separate 
pavilion,  or  shall  there  be  two  or  more  wards  in  each 
pavilion  ? 

No  one  will  attempt  to  deny  that  one-story  pavil- 
ions are  more  easily  ventilated  and  have  proportionate- 
ly a  greater  surface  exposed  to  sunlight  than  a  build- 
ing of  two  stories,  and  that  the  isolation  of  the  patients 
of  a  one-story  ward  is  more  complete  than  it  is  practi- 
cable to  attain  in  a  pavilion  containing  two  wards. 

It  is  said  that  one-story  pavilions  are  more  expen- 
sive: because,  to  build  a  hospital  of  one-story,  more 
ground-space  is  needed  than  for  two ;  that  two  pavil- 
ions of  one  story  are  more  costly  than  one  pavilion  with 
two  wards,  as  there  are  an  extra  roof  and  foundation ; 
that  the  administration  is  more  difficult ;  and  that  it 
requires  more  fuel  to  heat  wards  in  separate,  one-story 
buildino;s. 

In  answer  to  the  first  objection  as  to  the  ground, 
space,  we  would  say  at  once,  if  there  is  not  sufficient 
ground  for  one-story  buildings,  then  do  not  put  up  so 
large  a  hospital,  or  select  another  site  where  land  is 


COMPARATIVE  COSTS  OF  COXSTRUCTIOIT.  05 

cheaper ;  liaving,  if  necessary,  small  receptioii-liospitals 
and  ambulance-wagons  to  transport  the  patients.  It  is 
by  no  means  certain  that  wards,  one  directly  above  the 
other,  are  better  placed  than  when  separated,  even 
though  the  space  between  is  not  great.  It  is  claimed 
that  germs  float  horizontally.  But  we  know  how  soon 
the  outside  air  will  dilute  and  dissipate  foul  air ;  be- 
sides, we  know  that  almost  all  building-material  is  per- 
meable to  air  which  readily  passes  from  one  chamber 
to  another,  although  there  are  no  communicating  doors. 

In  answer  to  the  second  objection,  as  to  the  cost  of 
building — it  is  true  there  must  be  an  e5:tra  roof  and 
foundation,  but  the  foundations  need  not  be  so  deep  nor 
the  walls  so  heavy  in  one-story  as  in  two-story  build- 
ings, and  there  are  no  expensive  stairways  or  elevators 
as  in  the  two-story  buildings.  We  have  examined  the 
contracts  of  various  hospitals,  and  we  are  satisfied  that 
one-story  pavilions  are  but  little  more  expensive  as 
hospital-buildings  than  two-story  pavilions,  and  not 
so  costly  as  buildings  of  many  stories. 

The  new  pavilion  of  the  New  York  State  Woman's 
Hospital  of  three  stories  and  an  attic,  to  contain  be- 
tween sixty  and  sixty-five  or  seventy-five  beds,  has 
already  cost  $108,000,  and  it  is  estimated  that  $30,000 
more  will  be  required  to  finish  it ;  and  the  New  York 
Hospital  now  being  completed  is  a  building  of  seven 
stories,  to  contain  a  hundred  and  fifty  beds.  The  con- 
tract for  the  building  alone  is  $432,000.  This  gives 
for  the  Woman's  Hospital  pavilion  a  cost  for  the  build- 
ing alone  of  $2,143  to  each  patient,  and  of  $2,836  for 
the  New  York  Hospital.  The  contract  for  the  building 
of  the  one-story  pavilion  of  the  Presbyterian  Hospital 
of  Philadelphia  for  twenty-eight  beds  was  only  $12,000, 


96  CONSTRUCTION  OF  A    CIVIL  HOSPITAL. 

or  a  cost  of  $428  for  eacli  bed.  The  lieating  apparatus 
and  furnisliing  made  tlie  total  $15,000,  or  only  $535  for 
each  bed. 

Those  who  have  had  charge  of  hospitals  of  one-story 
buildings  claim  that,  as  all  the  wards  are  on  a  level, 
the  administration  is  easier ;  there  are  no  stairs  to  keep 
clean  and  ascend,  nor  elevators  and  lifts  to  work.  We 
admit  that  it  requires  more  fuel  to  heat  the  one-story 
wards,  but  we  do  not  consider  this  an  objection — on 
the  contrary,  an  advantage ;  if  fresh  air  enters  the  ward 
so  raj^idly,  then  we  can  be  sure  that  the  ventilation 
is  more  perfect.  In  very  cold  climates  double  walls, 
double  roofs,  and  plate-glass  windows,  can  be  used. 

Our  conclusion  is  that,  for  the  treatment  of  all  the 
classes  of  patients  we  have  enumerated  above,  it  is 
desirable  to  have  every  ward  in  a  separate,  one-story 
pavilion.  For  the  treatment  of  cases  coming  under 
Classes  II.  and  III.,  it  is  essential  that  the  wards  should 
be  in  one-story  pavilions.  For  the  treatment  of  Class 
IV.,  isolated  huts  or  tents  are  absolutely  necessary. 

Shall  the  Buildings  he  permanent  or  temporary  in 
Character  f — The  ancient  Jews  recos-nized  the  fact  that 
leprosy  would  infect  the  walls  of  a  house,  and  that  it 
was  necessary  to  scrape  and  purify  the  walls,  and  in 
some  instances  entirely  destroy  the  house,  to  prevent 
the  spread  of  the  disease.  And  it  is  an  undisputed 
fact  that  certain  infectious  diseases  will  poison  at  least 
for  a  time  an  apartment  so  as  to  render  it  dangerous  as 
a  habitation  ;  that  every  case  of  these  infectious  diseases 
evolves  poisonous  matter,  or  germs  that  are  liable  to 
cause  the  same  or  a  kindred  disease  in  other  persons ; 
that  if  not  all,  at  least  many,  of  these  disease-germs,  are 


DISEASE-GERMS  AND  DISINFECTANTS.  97 

conveyed  from  one  person  to  another  by  means  of  actual 
contact  of  clotliing  or  other  material  which  has  been  on 
or  about  the  person  infected ;  that  the  poison  is  spread 
by  the  air  itself  becoming  poisoned,  or  in  some  way  con- 
veying the  poisonous  matter  or  disease-germ  ;  and  that 
air  charged  with  these  germs  or  particles  is  liable  to 
deposit  them  on  all  surfaces,  and  in  all  the  openings, 
crevices,  or  pores,  into  and  through  which  it  permeates. 
Now,  the  latest  and  most  reliable  experiments  on  these 
infections  germs  or  particles  show  that  time  has  but  lit- 
tle, and  in  some  cases  no,  apparent  effect  on  their  vitality 
or  power  to  reproduce  disease,  and  that  the  substances 
known  as  disinfectants  cannot  be  said  always  to  destroy, 
but  only  to  prevent  for  a  time,  the  process  of  fermenta- 
tion or  decomposition,  or  the  develojDment  of  those  con- 
ditions which  seem  to  be  essential  to  the  active  state 
of  generation  and  propagation  of  the  poison.  To  have 
even  this  influence,  the  disinfecting  substance  must  be 
of  a  certain  strength,  and  be  made  to  reach  each  parti- 
cle or  germ. 

The  conclusion  is,  that  practically  the  majority  of  so- 
called  disinfectants  do  nothino;  more  than  substitute  one 
odor  for  another,  and  that  many  of  them  when  thorough- 
ly applied  can  only  be  relied  upon  to  allay  for  a  time 
the  active  condition  of  disease-germs.  Without  ques- 
tion intense  heat  of  several  hundred  degrees,  and  certain 
strong  corrosive  substances,  can  be  made"  to  destroy 
these  poisonous  germs ;  but,  both  experience  and  ex- 
perimental science  show  that  in  many  cases,  to  com- 
pletely destroy  these  germs,  without  at  the  same  time 
injuring  or  destroying  the  substance  or  material  infect- 
ed, is  impossible,  and  that  practically  the  task  is  so 
difficult  that  it  is  better  to  remove,  and  not  infre- 
7 


98  COHSTRTJGTION  OF  A    CIVIL  EOSPITAL. 

quently  it  is  best  to  destroy,  tlie  infected  substance  or 
material. 

It  is  a  well-kno\vn  fact  that  nearly  all  building- 
material  is  permeable  to  air.  Lately  Pettenkofer  bas 
sbown  by  experiment  that  a  difference  of  temperature 
in  tbe  air  of  a  closed  room  from  that  of  the  outside  air 
causes  a  free  flow  through  the  walls  of  the  room,  and 
that  the  quantity  of  air  passing  through  varies  accord- 
ing to  difference  of  temperature,  or  inequality  of  atmos- 
pheric pressure,  and  the  character  of  the  wall ;  but  that 
through  all  walls  more  or  less  air  will  pass,  and  that 
the  quantity  of  air  that  will  pass  through  an  ordinary 
brick  wall,  with  the  usual  plastered  surface,  is  very 
great.  He  says  that  in  the  case  of  an  ordinary  room, 
with  the  windows  and  doors  closed,  mth  an  open  fire 
burning,  more  than  half  the  air  that  enters  the  room 
and  passes  up  the  chimney  comes  directly  through  the 
walls. 

If  it  is  true  that  infectious  geims  are  floating  about 
in  the  air,  and  that  the  walls  are  permeable  to  air,  then 
it  is  easy  to  understand  that  the  walls  of  an  apartment 
would  be  liable  to  infection.  There  are  facts  that  go 
to  show  that  walls  do  become  infected  with  the  poison 
of  disease.  One  striking  instance  is  that  which  oc- 
curred in  1864,  when  a  ward  in  which  fever-cases  had 
been  treated  in  the  old  New  York  Hospital  was  being 
renovated.  "Out  of  five  masons  who  were  removing 
the  plaster,  three  died  of  fever  in  a  few  days."  * 

We  do  not  doubt  but  that  perfect  cleanliness  and 
careful  attention  to  ventilation,  etc.,  will  do  much  to 
prevent  the  infection  of  the  walls,  and  to  obviate  the 

•  Mr.  J.  "W,  Beekman's  "  Centennial  Address  "  before  the  Society  of  the 
i^ew  York  Hospital. 


^ 


CHARACTER   OF  TUE   WARD.  99 

cLaiiger  "svlien  tliey  are  infected ;  still  many  eases  will 
arise  wliere  the  saturation  of  the  walls  of  a  buildino:  in 
wliicli  a  number  of  infectious  cases  liave  been  treated  is 
such  as  to  demand  complete  destmction.  Disinfection 
and  j^urification  by  exjDOSure  to  the  weather  may  for  a 
time  remove  the  danger,  but  cannot  be  relied  upon  as 
certain  and  lasting  preventives.  Practically  it  is  a  very 
expensive  and  difficult  matter  to  secure  impermeable 
walls ;  and  even  if  walls  could  be  made  impermeable  to 
air,  it  is  doubtful  if  they  are  desirable,  on  account  of 
preventing  a  free  circulation  of  air  through  them,  and 
thus  interferino-  with  ventilation. 

In  answer  to  the  question  "  Should  the  wards  (not 
the  entire  pavilion,  for  we  have  the  service-rooms  in  a 
separate  building)  be  permanent  or  temporary  in  char- 
acter?" we  would  suggest  that  the  pavilions  for  the 
first  and  second  classes  of  cases  enumerated  be  perma- 
nent in  character,  but  that  those  for  the  third  class 
should  be  more  or  less  temporary  ;  those  for  the  fourth 
class,  of  course,  to  be  frecpiently  destroyed  and  re- 
newed. 

JSi'umler  of  Beds  to  each  Ward. — Givins:  full  con- 
sideration  to  the  number  of  sick  that  should  live  in  £>ne 
room,  and  to  economy  in  having  them  properly  attend- 
ed to,  from  twelve  to  thirty-two  has  been  found  by 
experience  to  be  about  the  range. 

Just  as  the  character  of  a  ward  should  depend  upon 
the  class  of  disease  to  be  treated  in  it,  so  should  the 
number  of  beds  in  each  ward  vary  with  the  class  of  dis- 
ease to  be  treated  in  them. 

For  medical  and  other  cases  not  infectious  or  liable 
to  become  so,  we  would  place  the  number  of  beds  at 


100  COXSTRUCTIOF  OF  A    CIVIL  HOSPITAL. 

from  twenty-five  to  twenty-nine  ;  for  surgical  and  otlier 
cases  not  infectious  but  likely  to  become  so,  from  nine- 
teen to  twenty-five ;  for  severe  cases  extremely  liable 
to  become  infectious,  and  always  dangerous  to  others, 
the  number  of  beds  to  the  ward  should  not  be  more 
than  from  twelve  to  sixteen.' 

Infectious  and  contagious  cases  in  connection  with 
a  general  hospital  should  be  at  once  removed  to  tents 
or  huts  containing  not  more  than  from  two  to  four  beds. 
The  number  of  beds  should  by  no  means  be  the  same 
as  the  number  of  patients  in  every  ward,  especially 
when  two  or  more  severe  cases  are  in  it.  There  should 
always  be  at  least  three  or  four  beds  empty,  so  as  to 
give  time  for  changing  and  cleaning  them,  and  so  that 
the  beds  adjacent  to  any  special  cases  could  be  left 
vacant. 

The  Cubic  Air-Space  to  each  Bed. — In  regard  to  the 
air,  the  important  point  is  to  insure  a  rapid,  constant, 
and  comj)lete  change  of  the  atmosphere  surrounding 
the  patient,  and  to  efi'ect  this  without  causing  hurtful 
draughts.  For  the  convenience  of  administering  to  the 
Avants  of  the  patient,  it  is  essential  to  allow  a  certain 
amount  of  cubic  air-space  and  surface  area.  About 
1,800  cubic  feet  of  air-space,  with  a  surface  area  of  124 
square  feet,  has  been  adopted  as  the  space  required. 
We  would  have  the  space  vary  in  accordance  with  the 
class  of  disease  to  be  treated  in  the  bed. 

The  dimensions  of  the  suro-ical  ward  containino- 
twenty  beds  should  be  the  same  as  the  medical  ward 

'  The  above  figures  are  given  supposing  the  dimensions  of  the  wards  for 
all  three  classes  to  be  the  same,  thus  giving  more  than  double  the  cubic  air- 
space to  the  third  class  that  is  allowed  to  the  first  class. 


SHAPE  AND  SIZE  OF  WARD.  101 

for  twenty-five  beds,  and  tlie  ward  for  twelve  danger- 
ous cases  sliould  be  the  same  size.  Thus,  say  that 
1,800  cubic  feet  in  the  medical  ward  are  allowed  for 
each  bed,  the  allowance  in  the  sursrical  ward  would  be 
2,100  cubic  feet,  and  3,600  cubic  feet  in  the  ward  for 
dangerous  cases. 

Slicqye  of  the  Ward. — The  shape  of  the  ward  usu- 
ally recommended  and  very  generally  adopted  is  that 
of  a  rectangle,  with-  a  width  of  from  twenty-four  to 
thirty  feet,  and  a  length  varying  with  the  number  of 
beds,  usually  about  three  times  the  extent  of  the  width. 
The  height  commonly  adopted  is  from  fourteen  to  six- 
teen feet. 

Within  the  last  four  years,^two  wards  have  been 
constructed  in  connection  with  the  Massachusetts  Gen- 
eral Hospital  at  Boston,  one  of  which  is  forty-four  feet 
square  and  the  other  forty-five  by  fifty-five.  The  square 
ward  has  some  advantao-es  over  the  elonsrated,  rectan- 
gular  form ;  but,  except  in  those  cases  where  the  num- 
ber of  beds  in  the  ward  is  so  small  that  the  square 
would  not  be  more  than  thirty  feet,  and  at  the  same 
time  allow  sufficient  air-sj^ace,  we  would  give  the  pref- 
erence to  the  elongated  ward. 

It  is  true  that  in  the  square  ward  the  fireplaces  or 
stoves,  and  the  ventilating-shafts,  can  be  placed  in  the 
centre  of  the  ward,  and  thus  be  more  nearly  equidistant 
from  all  the  beds,  whereas  in  the  lono;  ward  two  such 
shafts  are  necessary,  and  that  in  the  square  ward  the  pa- 
tients are  all  nearer,  and  more  convenient  to  the  service- 
rooms.  But  in  the  long  ward  there  is  more  wall-space, 
and  therefore  the  beds  are  not  so  near  each  other,  as  in 
a  square  ward  of  the  same  capacity ;  and  if  the  square 


102  CONSTRUCTION  OF  A    CIVIL  HOSPITAL. 

ward  exceeds  thirty  feet,  tliere  is  a  greater  volume  of 
air  to  be  moved  between  o^^j^osite  windows,  tlie  sun- 
light does  not  so  completely  reach  all  parts  of  the  ward, 
and  the  surface  of  the  ground  beneath  is  further  re- 
moved from  the  purifying  influences  of  light.  In  the 
square  ward  the  patients  are  nearer  the  service-rooms, 
but  at  the  same  time  they  are  more  in  danger  of  infec- 
tion from  that  source.  Then,  too,  if  the  service-rooms 
are  attached  to  one  of  the  four  sides  of  the  ward,  one- 
fourth  of  the  whole  wall-surface  is  cut  off  from  the  out- 
side air. 

We  would  make  the  ward  thirty  feet  wide,  fifteen 
feet  to  the  roof  at  the  eaves  (the  roof  having  a  slant  of 
not  less  than  thirty  degrees),  and  long  enough  to  give 
for  the  medical  ward,  nine  feet  of  wall-space  to  each 
bed,  for  the  surgical  ward  not  less  than  ten  feet,  and 
sixteen  feet  for  the  ward  for  dans^erous  cases. 

Position  of  the  Ward  in  Relation  to  the  Points  of 
the  Compass. — If  the  long,  rectangular  ward  is  adopted, 
then  it  is  essential  that  the  long  axis  of  the  ward  should 
be  from  north  to  south,  so  that  the  sun  will  shine  half 
the  day  on  one  side,  and  the  other  half  on  the  opj)osite 
side,  thus  exposing  the  largest  possible  surface  to  the 
influence  of  the  direct  rays  of  the  sun. 

Position  of  the  Service-Rooms. — ^The  usual  plan  is 
to  attach  the  service-rooms  of  the  ward  directly  to  the 
ends  of  wards ;  the  nurse's  room,  dining-room,  ward- 
kitchen,  and  extra  room  or  small  ward  containing  one 
or  more  beds,  being  attached  to  the  end  of  the  ward 
nearest  the  corridor,  being  in  reality  a  part  of  the  ward 
partitioned  off  with  a  hall-Avay  through  its  centre  and 


COXNBCTIOy  OF  SERVICE-ROOMS  WITH  WARD.     103 

connecting  directly  with  the  corridor  which  is  usually 
on  the  same  level  as  the  floor  of  the  ward.  At  the 
other  end  of  the  ward,  in  the  corners,  the  water-closets 
and  bath-room  are  usually  placed,  being  cut  off  from 
the  ward  by  lobbies.  In  some  cases  the  ends  of  the 
wards  containing  these  service-rooms  are  -widened  so  as 
to  leave  a  broad  passage-way  between  them,  at  the  end 
of  which  there  is  a  larg-e  mndow. 

o 

The  service-rooms  should  be  separated  from  the 
ward  and  in  a  distinct  building,  placed  at  the  north 
end  of  the  ward,  and  connected  with  it  by  means  of  a 
shoi*t  corridor.  This  corridor,  or  short  passage-way, 
should  project  from  near  the  centre  of  the  service-room 
building  until  it  reaches  a  point  when,  by  a  turn  at 
right  angles,  it  could  connect  with  the  war  J,  opening 
into  the  ward  on  the  side  in  the  corner.  This  short 
23assage-way  should  be  about  six  feet  wide,  so  as  to 
allow  a  man  to  be  carried  throu2:h  it  on  a  stretcher. 
It  should  be  carefully  guarded  by  swing-doors  where  it 
turns  at  right  angles  and  where  it  enters  the  ward,  so 
that  it  would  be  impossible  for  a  current  of  air  to  cir- 
culate through  it  from  the  service-room  to  the  ward, 
and  it  should  be  well  lighted  and  carefully  ventilated. 
Thus  we  have  the  ward  completely  isolated. 

The  objects  aimed  at  are — 1.  To  avoid  the  danger 
which  is  to  be  apprehended  from  the  proximity  of  the 
numerous  partitions,  doors,  etc.,  of  the  service-rooms  as 
affording  places  for  harboring  infection,  and  from  the 
emanations  from  water-closets,  drains,  sinks,  and  dining- 
rooms  ;  2.  To  diminish  the  risk  of  the  foul  air  of  one 
ward  reaching  other  wards  by  means  of  the  corridors ; 
3.  To  leave  the  ends  of  the  ward  free,  so  that  a  current 
of  air  can  pass  through  the  ward  as  readily  from  end  to 


104  COFSTEUCTIOF  OF  A    CIVIL  HOSPITAL. 

end  as  from  side  to  side ;  4.  That  if  need  be,  on  account 
of  tlie  ward's  becoming  infected,  it  can  be  destroyed, 
leavino;  tlie  basement  and  service  rooms  and  tlie  corri- 
dors  intact. 

In  a  long  ward  it  is  very  important  that  its  ends 
should  be  free,  so  as  to  allow  a  current  of  air  to  j)ass 
freely  and  without  the  risk  of  bringing  infection  from 
the  service-rooms,  for  in  all  long,  narrow  chambers  the 
natural  current  of  the  inclosed  air  is  in  the  direction 
of  the  long  axis,  being  that  of  the  least  resistance.  Be- 
sides, during  the  summer  months,  when  the  windows 
are  open,  the  prevailing  winds  in  our  vicinity  are  from 
tbe  south,  and  a  current  of  air  passing  from  end  to  end 
moves  a  volume  of  air  in  the  ward  through  an  open  end- 
door  or  window,  equal  to  at  least  three  times  as  much 
as  one  passing  through  a  window  from  side  to  side. 

The  Foundation  of  the  Ward. — The  foundation  of 
the  pavilions  of  a  temporary  hospital,  such  as  is  needed 
during  a  war,  may  be  of  a  very  simple  character;  but 
in  a  fixed,  civil  hospital  the  foundation  should  be  care- 
fully prepared,  especially  if  the  soil  is  not  just  what  it 
should  be.  The  ward  should  rest  on  pillars  of  masonry 
seven  or  eight  feet  above  the  level  of  the  surface  of  the 
ground,  and  arched,  so  that  the  floor  of  the  ward  would 
rest  on  an  asphalt  and  concrete  surface  to  give  it  firm- 
ness and  protection  from  cold.  If  the  pillars  are  of 
brick,  they  should  have  layers  of  slate  in  each  to  inter- 
cept the  passage  of  ground-air  up  through  them.  The 
surface  of  the  ground  beneath  the  ward,  between  the 
arches  and  for  several  feet  around  the  building,  should 
be  covered  with  several  inches  of  concrete  and  asphalt, 
and  left  open  to  the  air  and  Sun ;  for  we  know  that  air 


OBJECTIOSS  TO  BASEMENTS  AND   CELLARS.       105 

circulates  freely  in  the  ground,  and  tLat  a  lieated.  room, 
when  the  doors  and  tlie  windows  are  closed,  draws 
air  directly  from  the  ground ;  and  that,  as  malarial 
and  noxious  gases  float  near  the  ground,  there  is 
constant  danger  of  such  gases  being  drawn  into  the 
ward. 

In  very  cold  weather,  if  necessary,  glass  sashes  could 
be  placed  so  as  to  close  the  space  beneath  the  wards, 
but  it  should  not  be  kept  closed,  for  we  believe  all 
cellars  and  closed  chambers  of  air,  especially  without 
the  influence  of  sunlight,  to  be  injurious.  The  air 
confined  in  such  chambers  becomes  stagnant  and  pro- 
lific of  myriads  of  low  grades  of  life,  or  living  organ- 
isms, which  by  decomposition  soon  infect  it  with  poi- 
sonous matter,  and,  when  the  chambers  above  are 
heated,  this  foul  air  is  sucked  up  into  them  through 
the  walls  and  floors.  If  the  space  beneath  the  ward  is 
left  open  and  covered  with  concrete  and  asphalt,  danger 
from  the  ground-aii'  is  entirely  prevented. 

Material  for  huilding  the  Walls  of  the  Ward. — :The 
walls  of  the  pennanent  wards  should  be  of  well-made 
brick,  Avith  an  aii'-space  between  the  inner  and  outer 
surface  so  arranged  as  to  connect  with  the  space  be- 
tween the  roof  and  ceiling,  and  be  easily  ventilated  and, 
if  necessary,  fumigated.  We  would  give  the  preference 
to  bricks  over  wood,  and  to  wood  over  stone,  unless  the 
stone  was  porous  and  easily  worked.  As  wooden  walls 
are  cheaper  than  brick,  we  would  use  wood  in  construct- 
ing the  wards  of  a  temporary  character.  Walls  of  wood 
should  be  double,  with  an  air-space  between ;  this  is 
necessary  in  severe  climates  to  keep  out  the  cold,  and  in 
warm  climates  to  prevent  overheating.     In  warm  cli- 


106  CONSTRUCTION  OF  A    CIVIL  HOSPITAL. 

mates  tlie  space  "between  tlie  walls  sLould  be  arranged 
so  as  to  be  easily  ventilated  and  fumigated. 

Should  the  walls  of  tlie  wards  be  left  permeable,  or 
an  attempt  be  made  to  make  them  impermeable  to  air  ? 

The  object  in  making  the  walls  impermeable  to  air 
would  be  to  prevent  them  from  becoming  poisoned 
with  disease-germs,  or  infectious  particles,  or  gases. 

The  object  in  leaving  them  permeable  to  air  is  to 
allow  a  free  circulation  of  air  through  them.  It  is 
claimed  that  the  constant  passing  of  the  air  through 
the  walls  is  an  imj)ortant  part  of  ventilation ;  that  to 
make  the  walls  of  our  dwellings  impermeable  to  air 
would  be  as  objectionable  as  to  wear  a  rubber  suit  all 
the  time.  Walls  saturated  with  water  are  imjDermeable, 
and  it  is  said  that  this  fact  accounts  for  the  unhealthi- 
ness  of  houses  with  damp  w^alls. 

Besides  interfering  with  ventilation,  the  expense  of 
making  the  walls  impermeable  to  air  is  very  great,  and 
practically  very  difficult  to  accomplish.  Keen's  cement 
and  Parian  cement  have  been  found  about  the  best  sub- 
stances for  wall-finish.  Tiles  and  preparations  of  glass 
have  been  proposed,  and  we  have  suggested  sheet-zinc, 
or  sheet-iron  plated  with  zinc,  as  a  good  material. 

So  far  as  impermeable  walls,  or  walls  supposed  to 
be  impermeable,  have  been  tried,  in  Lariboisiere  and 
St.  Thomas's  Hospitals,  except  that  of  being  more  easily 
cleaned  than  the  ordinary  "hard-finish,"  certainly  no 
advantage  can  be  claimed  for  them ;  the  practical  re- 
sults on  the  patients,  so  far  as  reducing  the  death-rate, 
cannot  be  perceived. 

It  is  very  desirable  that  this  question  of  imper- 
meable walls  should  be  tested  by  carefully-conducted 
ex^^eriments   and   trials   made    under   similar   circum- 


PERMEABLE  OR  IMPERMEABLE  WAULS?  107 

stances.  But  since  experience  Las  slio^yn  tliat  excel- 
lent results — and,  so  far,  better  tlian  in  any  otlier  kind 
of  building  yet  tried — can  be  attained  by  treating  dis- 
ease in  simple  one-story  buildings  witli  tlie  ordinary 
walls,  we  would  adopt  the  ordinary  "  liard-finisli "  for 
the  permanent  buildings,  and  have  the  walls,  when 
well  settled  and  dried,  painted  and  varnished  to  the 
height  of  six  feet  from  the  floor.  For  the  walls  of  the 
temporary  pavilions  the  same  or  a  cheaper  material  could 
be  used.  Whenever  the  wall-plaster  shows  signs  of  age 
by  cracking  or  giving  way,  the  plaster  should  be  com- 
pletely renewed,  and  it  would  be  well,  at  intervals,  to 
scrape  and  renew  the  "  hard-finish "  in  the  permanent 
wards,  and  to  frequently  give  the  walls  of  the  tem23orary 
wards  a  coating  of  kalsomine,  and  those  for  dangerous 
cases  a  whitewashing  after  a  thorough  fumigation.' 

llie  Floors  of  the  Ward. — The  floors  should  be 
laid  on  a  firm  foundation,  so  as  not  to  spring  or  give, 
and  create  cracks.  The  space  between  the  beams  be- 
neath the  floor  should  communicate  with  the  space  in 
the  walls  so  as  to  admit  of  ventilation  and  fumigation. 
In  Europe  oak  seems  to  be  the  best  material,  but  in 
this  country  the  best  hospital-floors  we  have  seen  are 
made  of  closely-joined  Georgia  pine.  The  reason  why 
our  oak  floors  are  not  usually  good  is,  that  the  Quercus- 
alba  variety  is  the  only  oak-wood  which  will  make  good 
floors,  and  it  is  very  scarce  here  in  America. 

'  Mr.  Dougall,  of  Glasgow,  claims  that  the  presence  of  alkaline  sub- 
stances induces  decomposition  of  organic  matter ;  and  he  asserts  that  the 
alkaline  walls  of  hospitals,  and  the  soap  used  in  washing,  tend  greatly  to 
produce  infectious  germs  and  thus  cause  pyjemia  and  other  hospital-dis- 
eases. If  this  proves  to  ho  true,  then  a  complete  change  must  be  made  in 
the  character  of  the  walls  of  hospitals  now  in  use. 


108  CONSTRUCTION  OF  A   CIVIL  HOSPITAL. 

If  pine  is  used,  every  plank  sliould  be  carefully 
selected  as  being  well  filled  with  resin,  avoiding  those 
pieces  in  -wliicli  after  a  little  use  the  soft  part  will  wear 
away  and  the  hard  layers  shale  and  splinter  off,  leaving 
holes.  Shaling  does  not  depend  npon  the  quality  of 
the  pine,  but  upon  the  direction  in  which  the  saw  cuts 
the  annual  rings ;  the  saw  should  run  as  nearly  as  pos- 
sible in  the  line  of  a  radius  from  the  centre  of  the  log, 
to  turn  out  good  flooring-planks. 

The  floors  should  be  kept  smoothly  polished,  waxed, 
and  rubbed,  so  as  to  make  them  impermeable  to  water 
and  easily  cleaned  without  daily  or  frequent  scrubbing. 

The  WlndoiDS. — There  should  be  one  window  to 
each  bed.  The  height  of  them  in  all  of  the  wards 
should  be  from  within  two  feet  of  the  floor  to  within 
one  foot  of  the  ceiling  where  it  joins  the  wall.  The 
vddth  need  not  exceed  three  feet  in  the  medical  and 
permanent  wards,  but  should  be  full  three  feet  in  the 
temporary  wards,  and  still  wider  in  the  wards  for  dan- 
gerous cases. 

All  the  wood-work,  of  which  there  should  be  as  lit- 
tle as  possible  about  the  windows  and  in  the  ward, 
should  be  of  hard  wood,  with  all  corners  and  edges 
beveled  off  and  every  part  of  it  kept  well  waxed  and 
polished.     The  window-sills  should  be  of  slate  or  stone. 

For  the  sashes  thick  plate-glass,  or  single  sash  with 
double  glazing,  is  necessary  in  cold  climates,  and  is 
preferable  to  double  sashes  of  small  panes  of  thin  glass. 
Both  sashes  should  be  made  to  slide  easily.  The  blinds 
should  be  on  the  outside,  and  by  a  simple  contrivance 
could  be  worked  from  the  inside  without  opening  the 
window-sash.     In  one-story  pavilions  with  ridge-venti- 


WIND  0  W-  VENTILA  TION.  109 

lation,  louvres  over  tlie  windows  are  not  necessar}^  "but 
a  narrow  panel  ten  inches  deep  and  as  wide  as  tlie 
door,  just  above  tlie  upper  sash,  should  be  hung  witli 
hinges  at  the  bottom,  so  that  it  would  pull  out  at  the 
top  and  direct  the  air  upward  on  entering  the  ward. 

We  would  place  the  windows  directly  opposite  each 
other.  Alternate  windows,  or  windows  put  opposite 
to  the  wall-space  on  the  other  side,  were  tried  in  some 
of  the  temporary  army-hospitals  in  Paris  during  the 
late  Franco-German  AYar.  If  a  large  ward  had  only  a 
few  windows  in  it,  such  a  disposition  of  them  would  be 
an  advantage,  but,  when  they  are  as  numerous  as  we 
propose,  we  see  no  advantage  to  be  derived  from  it. 

The  Doors  and  Roof. — In  a  ward  there  should  be 
three  doors :  one  opening  into  the  short  corridor  which 
connects  with  the  service-room  building;  the  others, 
one  in  each  end  of  the  ward,  with  a  window  on  either 
side.  The  doors  should  also  be  made  of  hard  wood, 
perfectly  smooth,  without  mouldings  or  j^anels,  and  ke^^t 
well  polished. 

The  roof  should  be  of  slate,  with  an  air-space  be- 
tween it  and  the  ceiling  of  the  ward.  This  space  Should 
communicate  with  the  space  in  the  walls,  and  be  ar- 
ranged so  as  to  be  easily  ventilated  and  fumigated. 
The  ceiling  should  not  be  flat,  but  slope  up  and  slant 
parallel  with  the  roof,  and  be  rounded  at  the  ridge  and 
where  it  joins  the  wall,  so  as  not  to  have  angles.  The 
wall  in  the  four  corners  of  the  ward  should  be  rounded 
in  the  same  way. 

Tlie  Piazza. — The  door  in  the  south  end  of  the 
ward  should  be  wide  enough  to  permit  a  bed  to  pass 


110  CONSTRUCTION  OF  A    CIVIL  HOSPITAL. 

tliroiigli  it,  and  should  open  on  a  piazza  in  summer  and 
a  glass  sun-room  in  winter.  A  platform  or  flooring,  tlie 
width  of  the  ward,  and  projecting  out  twelve  feet,  with 
a  simple  framework,  over  wljich  an  awning  could  be 
stretched  in  summer  and  incased  with  sashes  of  class  in 
winter,  would  be  all  that  would  be  required.  A  stair- 
way or  an  inclined  plane  should  connect  the  end  of  the 
piazza  with  the  ground. 

THE  SERVICE-ROOM  BUILDING'. 

The  service-room  building  should  be  placed  near 
the  north  end  of  the  ward,  and  sejDarated  from  the 
ward  by  an  open  space  of  ten  feet,  and  sufficiently  at 
one  side  so  as  not  to  overlap  the  end  of  the  ward  more 
than  one-fourth  its  width.  In  this  position  it  would 
not  interfere  with  the  end-to-end  ventilation  through 
the  ward,  nor  intercept  the  sunlight. 

Dimensions  of  the  Building. — ^To  have  a  complete 
set  of  service-rooms  for  a  ward  of  twenty-five  beds,  the 
dimensions  of  the  building  should  be  thirty-four  feet 
wide  from  east  to  west,  by  forty-six  feet  in  length. 

Tlie  Basement. — The  basement  should  be  wholly 
above-ground,  so  as  to  make  the  floor  of  the  service- 
rooms  on  a  level  with  the  floor  of  the  ward.  The  base- 
ment of  this  building  should  be  divided  into  aj^art- 
ments,  for  the  heating  apparatus,  servants'  bedroom, 
and  store-rooms,  and  should  have  a  room  where  the  old 
clothes,  boots,  etc.,  and  effects  of  the  patients,  could  be 
stored  while  in  the  hospital.  In  this  room  there  should 
be  open-iuire  cages  built  round  against  the  walls,  one 
to  each  bed  ia  the  ward,  with  doors  and  locks,  instead 


SERVICE-ROOM  BUILDING.  Ill 

of  closed  closets.  In  the  end  of  tliis  room,  with  a  door 
023enmg  on  the  hall  in  the  basement,  there  should  be  an 
open-wire-work  closet,  in  which  Ijrooms  and  dust-pans 
should  be  kept.  The  doors  of  this  room  should  be 
made  to  fit  very  closely ;  for  the  window,  instead  of 
having  glass  window-sashes,  should  be  guarded  by  iron 
bars,  and  arranged  so  that  the  rain  would  not  beat  in, 
and  left  open,  in  order  that  the  old  clothes,  etc.,  should 
be  continually  exposed  to  the  purifying  influence  of 
fresh  air.  A  closed  apartment  filled  with  these  old 
clothes,  in  a  pauper-hospital,  soon  becomes  a  hot-bed 
of  infection.  It  should  be  a  corner-room,  so  as  to 
have  several  windows,  to  prevent  dampness.  The  stair- 
way from  the  basement  should  be  in  the  northeast  cor- 
ner, and  be  wide  and  easy  of  ascent,  and  ventilated  by 
three  windows,  and  should  be  cut  off  from  the  hall  of 
the  ser\dce-room  building  by  a  lobby  with  swing-doors. 

The  Service-Rooms. — The  first  floor  should  be  di- 
vided into  two  parts  by  a  hall  eight  feet  Avide  passing 
throusfh  it  from  north  to  south.  The  south-end  door  of 
this  hall  opens  into  the  short  corridor  which  connects 
the  service-room  with  the  ward;  and  the  door  at  the 
north  end  of  the  hall  should  open  out  on  the  top  of  the 
main  corridor. 

Wasli-Itoom  and  Wate?'- Closets. — On  enterino-  this 
hall  from  the  ward,  on  the  south,  there  should  be  on 
the  left-hand  side  a  door  opening  into  a  lobby,  six  by 
twelve  feet,  containing  a  sink  and  four  or  more  basins 
for  the  use  of  the  patients ;  the  lobby  should  have  a 
large  window  at  the  south  end,  and  two  doors  besides 
the  one  opening:  on  the  hall,  one  of  these  doors  leadinsr 


112  CONSTRUCTION  OF  A    CIVIL  HOSPITAL. 

to  the  water-closets,  wliicli  slioiild  be  in  a  room  eight  by- 
twelve  feet,  in  the  southwest  corner  of  the  building. 
The  closets  should  be  three  or  four  in  number,  and  in 
separate  stalls,  each  stall  having  a  window  opening  into 
the  outside  air. 

Batli-Room. — ^The  other  door  of  the  lobby  should 
open  into  the  bath-room,  which  is  ten  by  fourteen  feet, 
with  a  door  opening  on  the  hall,  and  two  windows  into 
the  open  air,  having  a  movable  bath  on  rollers  which, 
if  necessary,  could  be  run  into  the  ward,  and  two  stalls, 
one  for  hot  air,  the  other  for  steam-baths;  the  floor 
should  be  impervious  to  water. 

Day-Room  and  Dining -Room. — Next  to  the  bath- 
room on  the  same  side  of  the  hall,  occupying  the  north- 
east corner  of  the  building,  should  be  the  ward  day- 
room,  also  used  as  a  dining-room,  and  having  a  small 
scullery  with  a  little  stove  for  heating  and  cooking  cer- 
tain delicacies  (a  good  gas-stove  would  be  sufficient  for 
this  purpose),  and  a  sink,  etc.  The  day-room  should  be 
fourteen  by  eighteen,  and  the  scullery  six  by  fourteen 
feet. 

An  extra  room  or  small  ward  for  treating  certain 
cases,  which  would  be  better  alone  on  account  of  being 
troublesome  to  the  other  patients,  should  be  provided. 
This  room  should  never  be  used  for  isolating  infectious 
or  contagious  cases.  A  door  on  the  right,  at  the  south 
end  of  the  hall,  should  open  into  this  extra  room  or 
ward,  which  should  be  twelve  by  eighteen  feet,  and 
contain  two  beds — only  one  to  be  occupied  by  a  patient, 
the  other  to  be  used  in  case  of  the  need  of  a  special  at- 
tendant.    There  should  be  two  windows,  one  oj^en  to 


SERVICE-ROOM  BUILDING.  113 

tlie  east  and  one  to  tlie  south,  and  a  ventilating  open 
fireplace  in  tlie  northwest  corner. 

JVurse's  Moom  and  Linen-Shelves. — ^The  next  door 
on  the  right  of  the  hall  should  open  into  a  room  twelve 
by  ten,  in  which  should  be  open  shelves — not  closets  to 
cover  that  which  should  not  be  there — for  the  necessary 
clean  linen  for  the  ward.  This  room  should  have  a 
window  opening  into  the  outside  air,  and  a  bed  for  the 
ward-nurse,  only  to  be  used  in  case  it  is  occasionally 
thought  advisable  for  any  reason  that  the  nurse  should 
not  sleep  in  the  nurse's  home,  or  should  remain  near 
the  ward  on  account  of  some  important  case. 

deception  and  Examining  Hoom. — Beyond  this 
room,  on  the  same  side  of  the  hdll,  should  be  a  room 
ten  by  ten  feet,  with  one  window  arranged  so  as  to  give 
a  good  light.  In  this  room  should  be  an  Oj^erating  or 
examining  table  and  a  closet  for  medicines,  bandages, 
etc.,  and  a  bed  to  be  used  by  patients  while  recovering 
from  the  effects  of  an  ansesthetic.  This  is  the  reception 
and  examining  room,  also  to  be  used  for  minor  opera- 
tions on  patients,  when  it  is  not  desirable  to  convey 
them  to  the  operating-theatre. 

Every  door  in  the  service-room  building  should 
have  a  large  louvre  over  it,  and  be  placed  023posite  to  a 
door  on  the  other  side  of  the  hall,  so  as  to  establish 
direct  cross-currents  through  the  building.  The  door 
leading  into  the  short  corridor  should  be  low,  not  more 
than  seven  feet,  the  height  of  the  short  corridor,  so  that 
a  large  window  could  be  placed  above  it,  opening  into 
the  outside  air.  The  roof  of  the  service-room  building 
should  be  a  gabled  roof;  the  walls  of  the  building,  like 
8 


114  CONSTRUCTION  OF  A    CIVIL  HOSPITAL. 

tliose  of  the  ward,  being  fifteen  feet  from  the  eaves. 
The  ridge  of  the  roof  should  be  over  the  hall,  with  open- 
ings in  it  for  ridge- ventilation ;  or,  what  would  be  bet- 
ter, there  should  be  a  small  cap-roof  running  the  length 
of  and  over  the  hall,  with  a  space  between  it  and  the 
main  roof;  the  space  to  be  protected  by  movable  glass 
sashes. 

Such  a  service-room  building  as  we  have  described 
should  be  erected  with  the  permanent  wards  for  non- 
infectious cases  and  those  cases  not  dangerous  to  others, 
but,  in  connection  with  the  temporary  wards  of  only 
sixteen  beds,  the  service-room  building  need  not  be  so 
elaborate.  A  building  twenty-six  feet  square,  divided 
by  a  hall,  and  containing  bath-room  and  water-closets,  a 
small  day  or  dining  room,  an  extra  small  ward,  used 
also  as  an  examining-room,  and  a  nurse's  room,  would 
be  sufficient.  The  service-room  building  in  all  cases 
could  be  made  permanent  in  character,  for  the  ward 
could  be  removed  and  renewed  without  affecting  it. 

Great  care  should  be  used  to  prevent  any  contagious 
or  infectious  disease  being  treated  in  the  small  ward 
in  the  service-room  building,  otherwise  it  will  become 
poisoned. 

THE  MAIN  CORRIDOR. 

Except  where  the  severity  of  the  weather  makes  it 
necessary  that  there  should  be  a  closed  passage-way 
between  the  wards  and  the  administrative  building,  a 
simple  covered  way  with  a  track  for  tramway-carriages 
should  be  used,  not  only  for  the  sake  of  economy,  but 
for  sanitary  reasons.  A  long,  closed  passage  is  apt  to 
have  currents  of  air  flowing  through  it  in  the  direction 
of  its  length,  which  are  not  diverted  to  any  great  ex- 


MAIN  CORRIDOR   OR  PASSAGE-WAY.  115 

tent  by  opening  opposite  windows,  and  tlius  fonl  air 
is  readily  conveyed  from  one  end  of  the  corridor  to 
tlie  other,  and  will  find  its  way  into  any  buildino-  with 
which  the  corridor  is  connected. 

Besides,  a  corridor  running  over  the  ground  is  al- 
ways an  obstruction  to  the  free  circulation  of  the  air, 
and,  when  it  is  on  the  same  level  as  the  wards,  which  is 
usually  the  case,  it  is  a  very  serious  obstacle  to  the  cir- 
culation of  the  outside  air,  and  almost  sure  to  convey 
the  foul  atmosphere  from  one  ward  to  another. 

If  it  is  sunken  below  the  level  of  the  ground,  i.  e., 
is  a  basement  corridor,  then  it  is  a  chamber  filled  with 
air  continually  fouling  itself,  on  account  of  being  de- 
prived of  good  ventilation  and  sunlight ;  and  this  foul 
air  is  being  constantly  drawn  into  wards,  esj)ecially  in 
the  winter,  when  they  are  kept  warm,  and  outside  air 
is  barred  out. 

If  a  corridor  must  be  the  means  of  communication 
between  the  buildings,  then  the  wards  must  be  on 
basements  hio;h  enouorh  to  allow  the  corridor  to  be 
wholly,  above-ground,  with  its  top  not  higher  than  on 
a  level  with  the  floors  of  the  wards.  This  would  remove 
the  main  objection  to  corridors  as  obstructing  the  free 
circulation;  but  if  they  have  direct  connection  with 
the  wards,  or  with  a  hall  or  lobby  between  the  service- 
rooms  which  has  a  direct  connection  with  the  ward, 
there  will  yet  be  danger  of  their  doing  harm  by  carry- 
in  2:  foul  air  from  one  ward  to  another. 

It  is  to  obviate  these  dangers  that  we  have  pro- 
posed that  the  wards  should  be  on  arched  foundations, 
raised  so  that  the  floor  of  the  ward  is  eight  feet  from 
the  ground,  and  the  service-rooms  in  a  detached  build- 
ing connected  by  a  short  elbow-corridor   guarded  by 


116  CONSTRUCTION  OF  A    CIVIL  HOSPITAL. 

self-closino"  doors.  The  corridor  witli  its  floor  on  a 
level  with  tlie  ground  should  be  about  eight  feet  high, 
so  that  its  top,  as  we  have  said  above,  would  be  on  a 
level  with  the  floor  of  the  wards,  and  be  made  to  serve 
as  a  walk  to  be  used  in  pleasant  weather  in  passing 
from  one  buildinor  to  another.  The  inside  of  the  corri- 
dor  should  be  about  eight  feet  wide,  and  have  a  small 
tramway-track  for  carriages  in  which  the  food  and  pa- 
tients could  be  conveyed.  There  should  be  numerous 
windows,  and,  except  in  very  cold  weather,  those  on 
the  south  side  should  have  the  sashes  removed. 

The  corridor  should  connect  with  the  hasement  of 
the  service-room  building  on  the  north  end,  so  that,  to 
enter  the  ward  from  the  inside  of  the  corridor,  it  would 
be  necessaiy  to  go  into  the  basement  of  the  service-room 
building,  ascend  the  steps  to  the  hall,  and  then  go 
throuo-h  the  short  elbow-corridor. 

From  the  top  of  the  corridor  to  the  end-door  of  the 
ward  there  should  be  a  bridge :  during  pleasant  weath- 
er the  patients  could  thus  walk  directly  out  of  the  ward, 
and  take  an  airing  without  going  either  up  or  down 
stairs. 

In  one  of  the  five  essays  suggesting  plans  for  the 
Johns  Hopkins  Hosjoital,  the  author,  accepting  the  idea 
of  separating  the  service-rooms  from  the  ward,  has  given 
a  drawing  in  which  the  service-rooms  are  separate  from 
the  ward,  but  are  left  on  the  line  of  the  ward,  and  con- 
nected by  a  short,  straight  passage.  The  objection  to 
such  a  plan  is,  that  the  end-to-end  circulation  is  still 
seriously  interrupted,  and  the  chance  of  a  current  find- 
ing its  way  from  the  service-room  building  into  the 
ward  is  greater  than  when  the  service-room  building 
is  at  one  side,  and  is  connected  only  by  an  elbow-coiTi- 


MAIN  CORRIDOR   OR  PASSAGE-WAY.  117 

dor.  From  the  fiict  tliat  tlie  length  of  tlie  ward  and 
the  hall  of  the  service-room  are  on  a  line,  there  will 
always  be  a  tendency  to  draw  a  current  through  the 
neck ;  besides,  the  air  fi-om  the  windows  of  tlie  service- 
room  can  readily  find  its  way  into  the  end-windows  of 
the  ward. 

The  same  author  gives  a  drawing  in  which  the  main 
corridor  passes  between  the  ward  and  service-room 
building,  the  connecting  neck  being  on  top  of  it,  thus 
obliging  all  passers-by  to  go  through  it.  As  the  top 
of  the  corridor  will  be  used  during  the  greater  part  of 
the  year  for  the  general  passage-way  to  tlie  pavilions, 
the  communication  between  the  ward  and  the  service- 
room  would  be  very  much  exposed,  and  the  patients 
would  be  subjected  to  unpleasant  encounters  with  any 
one  who  might  be  passing ;  besides,  the  corridor  would 
be  so  close  to  the  ward  that,  during  the  winter  months, 
air  from  it  would  be  drawn  up  into  the  wards. 


CHAPTER  V. 

WARMIlSrG    ATfD    VENTILATION. 

Waeming  an  apartment  would  be  an  easy  and  very 
simple  process,  if  it  were  not  a  necessity  to  have  the  air 
frequently  changed  or  the  apartment  ventilated ;  and  if 
it  were  not  necessary  to  warm  the  air  that  enters  the 
room,  ventilating  an  apartment  would  be  comparatively 
easy.  During  cold  weather  the  two  must  work  con- 
jointly. 

That  system  of  warming  and  ventilating  is  the  best 
wliich  can  most  rapidly  and  comj)leteIy  remove  all  foul 
air  and  replace  it  with  air  as  pure  and  fresli  as  the 
normal  atmospliere  that  passes  over  tlie  huilding^  and  at 
the  same  time  keep  the  room  at  a  comfortable  tempera- 
ture, and  accomplish  this  without  causing  disagreeable 
or  hurtful  draughts,  injuring  the  building,  or  disturbing 
the  inmates,  and  at  the  smallest  cost. 

Since  so  many  conditions  must  be  fulfilled  to  secure 
perfect  ventilation,  it  is  easy  to  account  for  the  great 
difficulty  in  attaining  good  ventilation,  and  to  see  why 
so  many  plans  have  been  tried  and  why  so  many  fail. 

There  are  two  distinct  and  opposite  ways  of  chang- 
ing the  air  in  a  ward :  one  is  to  draw  off  the  foul  air  by 
suction  exhaustion,  and  allow  fresh  air  to  be  forced  in 


DIFFERENT  METHODS  OF  VENTILATING.  119 

by  atmosplieric  pressure.     The  type  of  tlie  metliods  for 
ventilating  by  suction  is  the  open  fireplace. 

The  other  way  of  renewing  tlie  air  is  by  driving 
fresli  air  into  the  ward  and  displacing  the  foul  air  by 
the  application  of  mechanical  force.  The  type  of  the 
methods  for  ventilating  by  means  of  mechanical  force  is 
the  fan-ventilator. 

The  term  "  natural  ventilation  "  has  been  applied  by 
writers  on  hospitals  to  the  method  by  suction  used  in 
conjunction  with  the  windows,  and  "  artificial  ventila- 
tion "  to  that  by  propulsion  or  the  fan-ventilator.  The 
terms  "  ventilation  by  exhaustion  "  and  "  plenum  venti- 
lation" are  also  used. 

In  ventilation  with  open  fire2:)lace  the  air  enters 
directly  from  the  outside  and  is  warmed  in  the  ward ; 
but,  when  the  fan  is  used,  it  is  necessary  for  the  air  to 
pass  through  a  channel  and  be  warmed  in  cold  weather 
before  it  enters  the  war^.  On  this  account,  when  the 
method  by  propulsion  is  used,  the  following  dangers 
must  be  o;uarded  aixainst :  That  the  air  before  it  enters 
the  ward  has  not  taken  up  any  foul  gas  or  substance  ; 
that  it  has  not  lost  any  of  its  oxygen  or  other  elements ; 
that  it  has  not  been  expanded  by  heat  without  a  proper 
amount  of  water  being  added ;  that  it  has  not  been  de- 
tained in  its  passage  long  enough  to  become  stagnant. 

Air  should  not  be  allowed  to  stand  still,  especially 
in  the  dark.  With  the  light  on  it  there  will  be  motion, 
for  light  produces  heat,  and  heat  causes  expansion,  and 
expansion  induces  currents,  unless  the  heat  is  equally 
distributed,  which  is  never  the  case.  Air,  like  water,  to 
keep  pure  and  fresh,  must  be  in  motion.  Air,  when  con- 
fined, in  a  very  short  time,  from  the  germs  that  all  air 
seems  to  contain  to  a  greater  or  less  extent,  will  foul  it- 


120  WARMING  AND    VENTILATION. 

self  by  tlie  biiili,  life,  deatli,  and  decomposition,  of  ani- 
malcules, and  soon  loses  its  vitalizing  power. 

In  ventilating  by  exhaustion  all  the  foul  air  passes 
out  by  one  or  a  limited  number  of  channels,  while  fresh 
air  enters  wherever  there  is  an  opening  and  directly 
through  the  walls  if  these  are  permeable  to  air.  It  is 
estimated  that  in  an  ordinary  house,  with  closed  doors 
and  windows,  one-half  of  all  the  air  enters  through  the 
walls. 

In  ventilating  by  propulsion  all  the  fresh  air  enters 
the  ward  by  one  channel,  or  necessarily  a  limited  num- 
ber of  channels,  while  it  escapes  from  the  ward  wher- 
ever there  is  an  opening,  and  through  the  walls  if  these 
are  permeable  to  air.  "When  the  doors  and  windows 
are  closed  we  can  assume  that  half  the  air  passes 
through  the  walls.  Now,  if  the  walls  are  permeable 
to  air,  and  if  there  are  organic  particles  and  disease- 
germs  floating  in  the  air,  it  is  very  evident  that,  if  half 
of  this  foul  air  is  forced  through  the  walls,  the  walls 
would  be  saturated  in  a  very  little  while  with  poison- 
ous matter,  and  that  a  strong  wind  impinging  on  the 
outside  wall  would  be  liable  to  force  this  poisonous 
matter  back  into  the  ward.  Besides,  such  an  accumu- 
lation of  poison  would  always  be  a  source  of  danger. 
Therefore,  if  the  plenum  or  propulsion  method  is  adopt- 
ed, the  walls  of  the  ward  sliould  he  impermeahle  to  air; 
while,  if  the  method  by  exhaustion  or  suction  is  used, 
the  incoming  air  would  tend  to  purify  j^ermeable  walls 
instead  of  poisoning  them. 

In  the  suction  method  half  the  fresh  air  permeates 
and  imperceptibly  enters  the  ward,  while  all  the  fresh 
air  in  the  plenum  method  comes  through  the  air-ducts. 
Thus  the  fresh  air  in  the  plenum  method  would  produce 


ASPIRATION  VERSUS  PROPULSION.  121 

mucli  greater  clrauglits  tliaii  in  the  method  by  exhaus- 
tion. These  draughts  would  be  very  objectionable  un- 
less the  air  was  warmed  before  entering  the  ward,  and 
even  then  Avould  often  be  disagreeable.  This  fact  also 
explains  why  the  anemometer  shows  motion  more  readi- 
ly in  a  room  ventilated  by  a  fan  than  in  one  ventilated 
by  an  open  fire :  it  is  commotion  to  a  certain  extent,  and 
not  the  steady  flow  created  by  an  open  fire. 

The  open  fire  is  troublesome,  and  causes  dust  and 
dirt ;  and,  unless  some  plan  is  adopted  by  which  a  part 
of  the  heat  that  would  ascend  the  flue  is  utilized,  the 
open  fire  could  be  called  expensive.  But,  by  regulating 
the  draughts  and  by  using  air-jackets,  or  hot-air  cham- 
bers so  arranged  as  not  to  bate  the  air,  an  open  fire  can 
be  made  comparatively  inexpensive. 

Practically  the  method  of  ventilating  by  the  fan 
cannot  be  applied  to  each  detached  ward  separately 
except  at  great  expense;  but  one  fan,  by  a  long  air- 
duct,  must  be  made  to  supply  several  wards  with  fresh 
air,  and  to  do  this  without  in  any  way  changing  the 
normal  condition  of  air  is  a  great  difficulty,  especially 
in  winter,  when  the  air  is  heated  before  it  enters  the 
ward. 

To  obviate  somewhat  this  difficulty,  we  would  sug- 
gest that  the  air-duct  from  the  f^m  to  the  Avards,  instead 
of  being  underground,  and  made  of  brick  and  cement, 
be  raised  several  feet  above  the  ground,  and  be  made 
principally  of  glass.  This  would  give  it  sunlight,  and 
remove  the  dansfer  of  OTound-air. 

To  prevent  the  air  when  heated  before  it  enters  the 
ward  from  becoming  dry — as  it  will  by  expansion  of  its 
vblume  and  consequent  increase  of  its  capacity  to  absorb 
water — the  heated  air,  instead  of  passing  over  water  for 


122  WAEMIXa  AXD    VENTILATION. 

only  a  sliort  distance  or  having  at  one  point  steam-spray 
thrown  on  it  while  passing  as  is  the  usual  mode  adopt- 
ed, should  be  made  to  pass  for  some  distance  directly 
over  a  broad  surface  of  running  hot  water,  so  as  to  give 
time  (which  is  an  important  element)  for  the  air  to 
absorb  sufficient  water  before  reaching  the  ward. 

In  public  buildings,  where  for  a  short  time  a  large 
number  of  people  are  necessarily  closely  crowded  to- 
gether, such  as  churches,  schools,  theatres,  legislative 
halls,  on  board  stcamshij)s,  and  in  all  hadly -constructed 
liosjyitals  or  other  inhabited  buildings,  ventilation  by 
the  plenum  method  or  the  use  of  a  fan  is  perhaps  the 
most  available  plan ;  but  we  do  not  consider  it  the  best 
method  of  ventilating  one-story  pavilion-hospitals  when 
the  wards  are  widely  separated  from  each  other  and 
from  all  other  buildings.  If  the  plenum  method  is  the 
best  method,  then  why  not  build  the  pavilions  with 
many  stories,  and  only  wide  enough  apart  to  admit 
sunlight,  and  keep  the  fan  going  winter  and  summer, 
havino"  the  fresh  air  brouMit  from  a  distance  ? 

We  do  not  discard  the  use  of  fan-ventilation  in  one- 
story  wards  upon  theoretical  grounds,  for  we  are  aware 
that  many  scientific  experimentalists  have  decided  in 
favor  of  the  plenum  method  of  ventilation  as  compared 
with  any  other  method ;  but,  so  far,  practical  exj)erience 
in  hospitals  has  shown  that  the  one-story  pavilion-hospi- 
tal with  the  exhaustion  method,  or  so-called  natural  ven- 
tilation, has  given  the  best  results  in  curing  the  sick,  and 
has  produced  fewer  cases  of  hospital-disease  than  any 
other. 

We  should  be  satisfied  to  alter  our  choice  if  by 
actual  trial  the  fan-ventilation  proved  to  be  beneficiaL 
But  the  success  attained  in  one-story  ward-pavilions 


DIFFERENT  METHODS  OF  WARMING.  123 

witli  open  fires  leaves  little  to  be  desired — not  enougli 
to  warrant  any  effort  toward  a  change  by  experiment- 
ing on  a  large  number  of  wards ;  nor  is  a  change  desir- 
able, except  in  so  far  as  economy  is  concerned. 

Warmiiig. — Heating  may  be  classed  under  two  gen- 
eral heads : 

1.  By  direct  radiation ;  that  is,  by  rays  of  heat  ema- 
nating directly  from  the  incandescent  body  in  which 
chemical  changes  are  producing  heat.  The  open  fire  is 
the  type  and  the  only  method  now  in  use.  Charcoal- 
braziers  are  rarely  used  since  chemistry  has  demon- 
strated the  danger  from  the  gases  given  off  by  combus- 
tion. 

2.  By  indirect  radiation ;  that  is,  by  the  heat  being 
transmitted  first  to  some  intermediate  body  and  thence 
to  the  air  and  bodies  in  the  ward.  The  closed  stove, 
coils  heated  by  steam  or  hot  water  circulating  in  them, 
and  hot-air  furnaces,  are  the  usual  methods  adopted. 

The  du'ect  radiation,  or  open  fireplace,  is  a  much 
more  cheerful  and  in  every  way  more  agreeable  method 
of  heating  to  most  persons,  except  for  the  accompanying 
dust  which  it  is  difficult  entirely  to  avoid.  The  open 
fire  does  not  seem  to  materially  change  or  injure  the 
normal  constituents  of  the  air. 

The  hot-air  furnace  is  the  least  desirable  method. 
It  has  all  the  bad  qualities  of  the  stove,  without  the 
advantage  of  the  slight  ventilating  draught  of  the  stove, 
while,  being  out  of  sight,  a  hot-air  furnace  not  only  con- 
tinually bakes  the  dust,  etc.,  in  the  air  and  deprives  the 
volume  of  air  of  its  normal  amount  of  air-moisture,  but 
it  is  also  liable  to  become  red  hot,  and  poison  the  air 
with  carbonic  oxide  which  passes  through  red-hot  iron 


124  WAEMMG  AND    VENTILATION. 

as  readily  as  tlirougli  a  sieve.  A  poorly-constructed  or 
badly-managed  stove  is  as  objectionable  as  a  furnace. 

Steam-heat  at  low  pressure  is  not  so  bad  as  tbe 
above,  but  is  not  so  agreeable  or  desirable  as  the  heat 
from  hot-water  coils.  Coils  of  hot-water  pipes  can  be 
kept  at  a  very  low  temperature,  and,  by  using  a  large 
number,  the  air  can  be  heated  to  an  agreeable  warmth 
and  without  materially  injuring  it,  the  air  passing  slow- 
ly and  in  a  large  stream  over  the  coils  before  it  enters 
the  room.  But,  to  produce  this  very  desirable  effect,  on 
account  of  the  large  amount  of  pipe  required,  it  is  a 
more  expensive  method  than  open  fires.  Still,  by  hav- 
ing the  water  below  200°  Fahr.,  as  coils  are  more  easily 
managed  than  open  fires,  they  are  very  useful  as  an 
auxiliary  or  supplement  to  open  fires  in  heating  and 
ventilating  a  hospital- ward.  The  Chinese  warm  their 
houses  by  means  of  furnaces  which  heat  the  floor  and 
walls  of  the  ajiartment,  the  hot-air  chambers  being 
beneath  the  floor  and  between  the  walls.  In  the  best 
houses  the  air  is  not  allowed  to  pass  directly  from  the 
hot-air  chambers  into  the  room,  but  must  transmit  its 
heat  throu2:h  the  medium  of  the  solid  walls.  If  heat- 
ing  is  the  only  object  aimed  at,  such  a  method  is  very 
economical,  and  the  warmth  is  evenly  distributed ;  but 
it  would  be  next  to  impossible  to  secure  walls  so  per- 
fect that  they  would  prevent  entirely  the  passage  of  the 
gases  of  combustion  from  entering  the  room.  Besides, 
the  advantage  of  porous  walls  would  be  lost,  and  ven- 
tilation would  be  difficult. 

Open  fires  have  this  very  great  advantage  over  any 
other  method  of  heating  a  hosjiital-ward,  that  at  the 
same  time  they  heat  they  prove  to  be  powerful  venti- 
lators. 


PROPOSED  METHOD   OF  WARMING.  125 

We  give  below  wliat  we  consider  one  of  the  best 
methods  of  ventilating  and  heating  a  one-story  ward 
such  as  we  have  described  as  being  thirty  feet  wide  by 
one  hundred  feet  long. 

Ward  Heating  and  Ventilation, — In  each  ward 
there  should  be  t^vo  main  heatins:  and  ventilatinsf  shafts 
placed  at  a  distance  of  twenty-five  feet  from  either  end 
on  the  long  axis  of  the  ward.  They  should  be  circular 
columns  of  masonry  about  three  and  a  half  feet  in 
diameter,  passing  up  from  the  basement  through  the 
ward  and  above  the  roof.  In  these  shafts  there  should 
be  two  open  fireplaces  or  open  soai:)stone  stoves  with 
their  backs  to  each  other  and  facing  the  line  of  the  short 
axis  of  the  ward.  From  the  outside  a  duct  for  fresh 
air,  with  a  liigli  lead  so  as  to  get  pure  air  and  avoid 
surface  or  ground  air,  should  lead  to  a  hot-air  chamber 
behind  each  fireplace,  which  should  have  an  exit  for  the 
wanned  air  into  the  ward  about  three  and  a  half  feet 
from  the  floor.'  This  exit  should  be  covered  and  res^u- 
lated  by  a  register  on  the  sides  of  the  ventilating  shaft 
facing  the  side-walls  of  the  ward.  The  four  fire2:)laces 
would  usually  be  sufficient  to  heat  the  ward,  but,  as  an 
auxiliary  in  severe  weather,  there  should  be  boxes  of 
hot-water  coils  between  the  walls  in  each  of  the  four 
corners  of  the  ward,  which  would  connect  with  a  fresh- 
air  duct  from  the  outside,  and  have  warm-air  registers 
opening  in  the  ward  near  the  floor.  These  hot- water 
coils  could  be  placed  just  below  the  floor,  in  boxes  well 
protected  from  the  cold,  having  valves  in  tlieir  fresh-air 
ducts,  with  handles  in  the  ward,  so  as  to  easily  regulate 

'  These  hot-air  chambers  should  be  so  constructed  as  not  to  overheat  or 
bake  the  incoming  fresh  air. 


126  WARMING  AND    VENTILATION. 

tlie  amount  of  cold  air  admitted.  The  hot-water  pipes 
could  run  between  the  floor  or  in  well-protected  boxes 
just  beneath  the  floors. 

Ward  Ventilation.  —  During  the  winter  the  four 
open  fireplaces  should  be  the  principal  ventilators. 
The  means  of  admitting  fresh  air  should  be  the  ducts 
connected  with  the  hot-air  chambers  behind  the  fire- 
places, and  the  boxes  of  hot- water  coils,  the  small  sash 
on  hinges  at  the  top  of  the  windows;  and,  besides, 
there  should  be  three  fresh-air  ducts,  one  in  the  centre 
of  the  ward,  and  the  other  two  between  either  chimney 
or  ventilating;  shaft  and  the  ends  of  the  wards.  These 
fresh-air  ducts  should  be  about  twelve  inches  in  diame- 
ter, extending  directly  through  the  ridge  of  the  roof  to 
a  short  distance  above  the  roof,  where  they  are  protect- 
ed by  a  cap,  and  where  the  fresh  air  enters  them.  At 
this  end  there  should  be  a  cover  or  valve  that  could  be 
worked  from  the  ward  to  cut  off  the  draught  at  pleasure. 

These  ducts,  made  of  thick  wood,  so  that  the  aii'  of 
the  ward  would  not  readily  heat  them,  should  project 
down  into  the  ward  until  within  seven  and  a  half  feet 
of  the  floor,  where  there  should  be  an  adjustable  scatter- 
plate  placed  beneath  the  open  end,  to  prevent  the  cold 
from  falling  in  a  mass  and  to  divert  any  chance  out- 
ward  currents,  and  at  the  same  time  scatter  the  fresh 
air  and  direct  it  upward.  We  have  thoroughly  tested, 
this  method  of  admitting  the  fresh  air  by  two  such 
shafts  in  a  hut  with  an  open  stove,  and  find  that  it 
admits  cold  fresh  air  into  a  heated  room  to  better 
advantage  than  any  method  we  have  seen. 

The  objects  aimed  at  in  contriving  these  air-ducts 
were — 1.    To    introduce    cold    fresh    air    and    avoid 


PROPOSED  MEinOD   OB    YEXTILATIOX.  127 

draughts ;  2.  To  introduce  the  heavy  cold  air  in  such 
a  way  that  in  falling  to  the  floor  it  would  assist  venti- 
lation by  driving  the  foul  air  downward  and  outward. 
This  method  of  introducing  the  cold  air  forces  the  foul 
gases  and  effete  and  poisonous  organic  matter  down- 
ward, which  is  the  dii^ection  they  naturally  take  when 
undisturbed  by  currents  of  some  force  in  an  upward 
direction.  With  every  expiration  a  certain  amount  of 
carbonic-acid  gas  and  effete  organic  matter  is  thrown 
off  by  the  lungs.  The  carbonic-acid  gas,  being  of  a 
higher  specific  gravity  than  air,  sinks  to  the  floor.  The 
organic  matter,  when  first  thrown  off,  is  held  in  solution 
by  the  watery  vapor  of  the  breath.  This  watery  vapor, 
comfeis:  in  contact  with  cold  air,  condtenses  and  carries 
with  it,  either  in  solution  or  in  the  form  of  solid  2:)arti- 
cles,  the  organic  matter  to  the  floor.  If  the  vapor  does 
not  condense,  the  water  is  taken  up  by  the  air  and  the 
organic  matter  set  free  in  the  form  of  solid  particles, 
which  soon  fall  to  the  floor.  This  and  similar  effete 
organic  matter  is  what  either  produces  or  at  least  forms 
the  nidus  for  disease-germs.  Now,  it  is  found  by  ex- 
periment that  in  the  air  of  a  closed  chamber,  where 
the  atmosphere  has  been  still  for  some  time  and  is  left 
undisturbed  by  currents,  these  germs  will  also  settle, 
so  that  fresh  meat,  milk,  or  vegetables,  will  remain  for 
days  undisturbed  by  the  process  of  decomposition  or 
fermentation,  which  always  indicates  the  presence  of 
spores  or  bacteria,  the  product  of  these  invisible  germs. 
From  the  above  it  is  plain  that  a  downward  current 
would  remove  these  poisonous  gases  and  particles  by 
the  most  direct  route  and  in  the  direction  they  natu- 
rally tend  to  take  when  left  to  themselves,  and  it  is 
equally  obvious  that  agitation  of  the  air  and  upward 


128  WARMING  AND    VENTILATION. 

currents  cause  tliem  to  float  about  and  settle  and  adhere 
to  tlie  walls  and  remain  longer  in  wards. 

3.  That  while  descending  the  air  would  be  moder- 
ately warmed  and  thus  avoid  a  cold  stratum  of  air 
along  the  floor,  which  is  likely  to  be  the  case  in  rooms 
heated  by  open  fires,  and  is  sure  to  be  the  case  if  the 
cold  air  is  admitted  at  or  near  the  floor  or  in  the  side- 
walls.  The  descending  shaft  is  necessary,  for  any  open- 
ing in  a  heated  room  that  is  in  or  near  the  ceiling  will 
act  as  an  exit  for  the  heated  air  which  always  tends  to 
ascend,  unless  the  counter-suction  is  very  powerful  and 
the  air  of  the  room  but  slightly  heated. 

In  connection  with  these  fresh-air  ducts — to  j)erfect 
the  process  and  prevent  the  fresh  cold  air  as  it  leaves 
the  ducts  from  being  drawn  toward  and  uj:)  the  chim- 
ney in  23lace  of  the  foul  air — there  should  be  a  number 
of  openings  in  the  floor  about  three  feet  from  the  walls 
and  directly  under  the  beds.  These  openings  should 
lead  into  foul-air  ducts  which  run  between  the  floors 
and  connect  with  a  large  foul-air  shaft  in  the  column 
of  masonry  surrounding  the  flues  of  the  two  fireplaces. 
The  flues  of  the  fires  should  be  of  thin  iron  so  as  to 
heat  this  large  foul-air  shaft  and  cause  a  powerful  suc- 
tion on  the  smaller  foul-air  ducts.  In  the  trials  that 
were  made  in  the  hut  alluded  to — a  hut  twenty  feet 
square  with  two  descending  fresh-air  ducts — there  were, 
connected  with  the  large  shaft  surrounding  the  stove- 
pipe, three  foul-air  ducts  with  openings  under  the  beds. 
When  a  fire  was  lio-hted  in  the  stove,  shavino-s  were 
drawn  into  the  openings  under  the  beds  and  were  car- 
ried along  up  and  out  into  the  open  air. 

In  the  permanent  wards  with  twenty  or  more  beds 
there  should  be  a  foul-air  duct  opening  under  each  bed. 


FOUL-AIR  ESCAPES.  129 

These  foul-air  ducts  should  Le  al)out  six  inches  in  diame- 
ter, of  cast-iron  as  perfect  as  the  best  gas-pi [)es,  and  so 
arranged  that  with  a  graded  slope  and  by  means  of 
openings  closed  by  screw-caps,  near  where  they  con- 
verge and  enter  the  large  foul-air  shaft,  they  could  be 
washed  by  pouring  water  in  these  openings  and  allow- 
ing it  to  pass  out  by  a  small  tube  which  runs  from  the 
end  under  the  bed  through  the  outside  wall.  This 
small  drain-pipe  should  also  be  closed  by  a  screw-cap. 
Disinfecting  water  could  be  used  when  necessary. 
As  the  openings  would  be  under  the  beds,  they  need 
not  be  covered  by  a  register,  but  during  the  summer 
when  not  in  use  should  be  closed  and  cleaned  res^u- 
larly.  These  openings  should  be  fully  as  large  as  the 
ducts. 

Besides  the  means  for  the  escape  of  the  foul  air  up 
the  chimney  and  out  at  the  foul-air  shafts,  there  should 
be  several  openings  along  the  ridge  of  the  roof,  which 
could  be  opened  or  closed  at  pleasure,  for  the  purpose 
of  giving  exit  to  the  hot  air  in  the  upper  part  of  the 
ward,  whenever  it  is  desirable. 

During  the  spring  months,  when  it  is  not  cold 
enough  for  a  fire  nor  warm  enough  to  oj^en  windows 
wide,  the  hot-water  coils  could  be  used  to  give  the 
desirable  warmth.  For  use  at  such  a  time,  and  even  in 
the  summer  when  with  the  windows  open  the  air  is 
heavy  and  still,  there  should  be  a  special  arrangement 
for  creatius;  a  drauo;ht  without  heatins:  the  air  of  the 
ward.  At  this  time  a  fan-ventilator  would  be  useful, 
and  one  of  Desao-ulier's  fan-ventilators  invented  in 
1727,  to  be  worked  by  hand,  could  be  tried.  A 
draught  could  be  secured  by  means  of  a  small  furnace ; 
or,  rather,  places  for  lighting  fires  in  should  be  ar- 
9 


130  WARMING  AND    VENTILATION. 

ranged  beneatli  tlie  ward  in  tLe  base  of  the  ventilating 
column.  The  draught  from  these  fires  should  pass  up 
throu2:h  the  large  foul-air  shafts,  and  thus  cause  sue- 
tion  on  the  foul-air  ducts  without  heating  the  air  of  the 
ward. 

To  make  a  draught  in  summer,  perhaps  a  better  way- 
would  be  to  arrange  a  number  of  hot- water  j^ipes  in  the 
corner  space  in  the  ward,  behind  the  coil  used  in  win- 
ter, so  as  to  create  a  draught  in  a  shaft  directly  in  the 
corner  with  an  air-space  and  the  masonry  intervening 
to  prevent  heating  the  air  of  the  ward.  Gas-jets  in  the 
same  position  could  be  used. 

Ligliting  the  Ward. — If  gas  is  used,  the  pipe  should 
enter  the  ward  throuo;h  the  elbow-corridor  from  the 
service-room ;  and  in  all  parts  except  just  where  it 
passes  into  the  ward  it  should  be  exposed  to  view,  and 
kept  in  perfect  order.  Three  or  four  jets  at  intervals 
under  the  ridge  of  the  roof  would  be  sufficient.  Each 
jet  should  be  covered  with  a  glass  globe,  the  opening 
at  the  top  of  which  should  be  continuous  with  a  tube 
leading  directly  into  the  open  air,  thus  at  once  remov- 
ing the  gases  of  combustion. 

No  water-pipes  should  be  laid  in  the  ward,  and 
under  no  circumstances  should  any  drainage-pipes  be 
either  under,  in,  or  about  the  ward-huilding. 

Ward-Furnitu7'e. — There  should  be  a  centre-table 
for  use  while  wounds  are  being  dressed,  and  for  merely 
temporarily  setting  things  down  on ;  but  usually  there 
should  be  nothing  on  it.  The  necessary  medicines,  in- 
struments, etc.,  used  by  the  doctors,  could  be  brought  in 
on  a  rolling;  table  durins:  their  visits  and  then  removed. 


WAED  SERVICE-ROOM  BUILDING.  131 

Tliis  table  sliould  be  a  slab  of  thick  glass  on  a  simple 
polished  iron  frame  and  should  have  soft-rubber  rollers. 

By  the  side  of  each  bed  there  should  be  a  small 
table,  merely  a  glass  slab  fixed  on  an  iron  frame,  and 
a  bent-wood  chair  with  arms,  and  a  wooden  bottom 
curved  to  make  it  comfortable,  but  every  part  smooth, 
without  holes,  and  kept  polished.  If  softer  material  is 
desirable  for  certain  cases,  rubber,  air  or  water  cushions 
should  be  supplied,  but  no  wool,  hair,  or  other  kinds 
of  cushions,  should  be  allowed  in  the  ward. 

The  bedsteads  should  be  of  wrought-iron,  nickel- 
plated,  with  the  improved  wire  mattress,  and  when 
necessary  horse-hair  mattress  cleaned  and  fumigated 
frequently ;  the  size  .of  the  bed  to  be  three  feet  wide 
by  six  and  a  half  long  and  two  and  a  half  feet  high, 
and  without  curtains.  In  movina;  the  beds  two  bars 
with  rubber  rollers  to  slip  on  the  feet  should  be  used. 

Every  ward  should  have  two  screens  in  three  folds, 
and  so  large  that  with  the  two  a  bed  could  be  sur- 
rounded on  three  sides,  yet  giving  room  sufficient  to 
handle  the  patient.  The  frames  of  these  screens  should 
also  be  of  wrought-iron  and  nickel-plated,  and  covered 
with  white  linen  tied  on,  so  that  it  could  be  removed 
and  a  fresh  ^over  put  on,  at  least  once  a  week.  Noth- 
ing more  is  needed  as  furniture  in  the  ward. 

All  urinals^  hed-pans,  spit-cups,  etc.,  should  be  of 
glass,  instead  of  porcelain  ;  for  the  least  crack  or  shale 
in  porcelain  or  imperfection  of  the  glazing  will  allow 
organic  matters  to  be  absorbed  and  thus  make  them 
poisonous. 

It  would  be  better  to  supply  each  patient  with  slip- 
pers having  rubber  heel-tips  to  wear  in  the  ward,  if  the 
floors  are  slippery,  than  to  use  carpets. 


132  WARMING  AND    VENTILATION. 

Attaclied  to  tlie  wards  tliere  sliould  be  a  liand- 
carriage,  on  wlieels  covered  with  rubber,  for  conveying 
the  patients  about,  and  a  bath-tub  on  rollers  of  rubber. 

Heating  and  ventilating  tlie  Service- Hooni  Build- 
ing.— Instead  of  the  usual  methods  of  haviug  the  heat- 
ing apparatus  in  one  central  building,  or  a  general 
boiler-house  from  which  all  the  pavilions  receive  their 
supply  of  steam  or  hot  water,  it  is  preferable,  on  account 
of  the  wide  separation  of  the  pavilions,  that  there  should 
be  a  small  boiler  in  the  basement  of  each  service-room 
building  which  would  supply  the  ward-coils  with  hot 
water,  and  also  heat  the  service-room  building,  the 
elbow-corridor,  and  a  certain  j^roportion  of  the  main 
connecting  corridor  if  necessary.  As  the  main  corridor 
is  cut  off  from  all  the  buildings  by  doors,  if  well- 
arranged  tramway-cars  are  suj)plied  for  carrying  the 
patients,  and  others  for  conveying  the  food,  it  would 
not  be  essential  to  heat  the  corridors ;  they  may  be 
merely  closed  passage-ways,  or,  what  would  be  better, 
a  sim23le  covered  way  protected  by  sashes  on  the  north 
side  in  winter. 

The  ventilation  of  the  service-rooms  should  be  as 
carefully  attended  ■  to  as  that  of  the  ward^  A  foul-air 
shaft  should  be  arranged  around  the  flue  of  the  furnace, 
and  foul-air  ducts  similar  to  those  in  the  ward  should 
open  into  the  different  rooms,  es23ecially  the  water- 
closets;  and,  if  considered  desirable,  downward  ventila- 
tion for  each  closet  could  be  arranged. 

The  small  ward  for  special  cases  should  have  con- 
nected with  the  open  fire  in  it  a  foul-air  shaft  and  have 
a  foul-air  duct  under  each  of  the  two  beds ;  also  a  fresh- 
air  duct  coming  in  from  under  the  eaves  till  it  reaches 


WAEB  SERVICE-ROOM  BUILDING.  133 

tlie  centre  of  tlie  room,  tlien  tiirniug  at  right  angles  and 
descending  to  within  seven  feet  of  the  floor,  having  a 
scatter-plate,  etc. 

The  stairway  from  the  l)asement  in  the  northeast 
corner  shoukl  be  thoroughly  ventilated,  and  cut  off 
from  the  hall  by  a  lobby. 


CHAPTER    VI. 

PAT-PATIENTS    IX    CIIAEITABLE   IXSTITUTIOXS. 

As  we  have  said  before,  we  believe  liosj)itals  as 
cLaritable  institutions  slionld  be  limited  to  tlie  sick 
poor  witliout  homes ;  that  every  effort  should  be  made 
to  improve  the  condition  of  the  homes  of  the  poor,  and 
to  teach  the  poor  to  avoid  sickness,  Now,  it  seems  to 
us  that  it  would  be  a  move  in  the  wrong  direction  to 
offer  an  inducement  to  the  sick,  either  poor  or  rich,  to- 
leave  their  homes  and  enter  a  hosj)ital  to  be  treated, 
especially  if  the  hosj^ital  is  called  a  charitable  insti- 
tution. 

Independence  and  charity  are  incomj^atible.  If  the 
pay-patients  do  not  receive  greater  care  and  attention 
and  better  food,  there  will  be  a  strong  temj^tation  for 
them  to  claim  to  be  subjects  for  charity,  so  as  to  save 
their  money.  We  have  seen  this  tested  in  one  of  our 
large  pauper-hospitals :  as  soon  as  the  patients  in  the 
pay- wards  learned  that  they  were  no  better  off  than 
those  in  the  free  wards,  they  would  almost  without 
exception,  by  failing  to  pay  after  the  first  installment, 
claiming  to  be  too  poor  to  afford  it,  endeavor  to  get 
into  "the  free  wards.  After  a  short  time  the  pay-ward 
was  abandoned  as  a  failure ;  and,  so  far  as  we  know,  the 


PROVIDENT  DISPENSARIES.  135 

plan  of  having  pay-patients  in  the  general  wards  of  any 
of  our  charitable  hospitals  is  practically  a  failure,  and 
is  maintained  more  for  the  pui'pose  of  keeping  out  un- 
desirable cases  than  for  the  income  derived  from  those 
willing  to  pay.  The  private-room  plan  succeeds  better, 
but  a  j^rivate  room  cannot  be  kept  ujd  in  a  public  hos- 
pital at  less  expense  than  in  a  private  house  or  private 
hospital,  for  the  doctors  are  the  only  unpaid  officials, 
and,  unless  the  pay-patient  is  made  to  pay  for  the  doc- 
tor's service,  the  private  rooms  will  not  materially  add 
to  the  income  of  the  hospital. 

If  the  attending  physicians  and  sui'geons  of  all 
our  charitable  institutions  would  refuse  to  attend  pay- 
patients  in  these  institutions,  private  self-supporting 
hospitals,  entirely  independent  of  charity,  and  free  from 
the  stigma  of  pauperism,  would  soon  arise  in  sufficient 
number  to  supply  all  persons  able  and  willing  to  pay 
for  hospital  treatment.  Such  a  step  would  be  not  only 
best  for  the  whole  community,  on  account  of  its  doing 
away  with  a  custom  that  tends  to  increase  pauperism, 
but  would  be  at  the  same  time  an  act  of  justice  toward 
their  professional  brethren  who  are  not  so  fortunate  as 
to  hold  a  position  on  the  medical  staff  of  a  hospital. 
The  above  remarks  are  equally  as  applicable  to  dispen- 
saries for  out-door  patients  as  they  are  to  hospitals  for 
in-door  patients.  The  free  and  the  pay  dispensaries 
should  be  separate  and  distinct  institutions,  the  free 
being  based  upon  charit}"  and  strictly  limited  to  the 
needy,  the  pay  being  based  upon  utility  and  being  self- 
supporting  institutions,  as  independent  of  charity  and 
as  free  from  all  connection  with  pauperism  as  a  life- 
insurance  company  or  any  other  private  corporation. 
A  "  provident  dispensary  "  claiming  to  be  a  charitable 


13G    PAY-PATIENTS  IN  CHARITABLE  INSTITUTIONS. 

institution  will  supply  a  more  enticing  stepping-stone 
to  pauperism  tlian  is  now  so  ud guardedly  offered  by  our 
badly-managed  free  out-door  dispensaries.  But,  if  a 
well-regulated  system  of  pay-dispensaries  organized  as 
independent,  self-supporting  institutions  could  be  made 
to  supj^lant  tlie  many  free  charity  dispensaries  at  pres- 
ent existing  on  the  plan  of  "  free  soup-liouses,"  medi- 
cine being  given  instead  of  soup,  we  believe  much  good 
would  be  done. 

At  present  the  custom  is,  to  offer  hospital  accommo- 
dations to  any  who  are  willing  to  ]3ay  for  the  care  and 
attention,  and  to  ask  the  medical  profession  to  attend 
such  persons  without  remuneration.  This  custom  is  in 
2')rinciple  an  injustice,  but  practically,  as  yet,  the  num- 
ber of  pay-patients  in  public  hosj^itals  has  not  been 
large.  Such  persons  are  charged  a  small  sum  if  j)oor, 
and  put  in  the  wards  with  the  other  patients,  or 
charged  a  high  price  if  rich,  and  given  a  |)rivate  room. 
Patients  in  private  rooms  should  be  allowed  to  select 
any  ph^^sician  on  the  medical  board,  and  to  j)ay  him  for 
his  services,  in  addition  to  what  they  pay  the  hosj^ital. 

We  will  assume  that  thirty-two  such  rooms  are 
needed,  twenty  for  men  and  twelve  for  women, 

Pay-  Wards. — These  wards,  divided  into  two  sepa- 
rate rows  of  rooms,  should  be  constructed  on  the  same 
principles  as  the  other  wards.  They  should  be  only 
one  story  high,  and  the  service-rooms  should  be  in  a 
separate  building,  and  cQnnected  by  an  elbow-corridor 
with  the  ward.  The  ward  should  be  on  a  raised  base- 
ment similar  in  every  respect  to  the  other  wards,  and 
should  have  its  piazza  at  the  south  end.  The  ward 
should  be  thirty-two  feet  wide  with  a  hall  through  the 


WAEDS  FOE  PAY-PATIENTS.  I37 

centre  eight  feet  wide,  witli  rooms  on  eitlier  side  twelve 
feet  deep  by  fourteen  wide,  two  of  the  rooms  being  six- 
teen by  eighteen  feet  for  two  beds,  as  it  is  sometimes 
desirable  to  have  an  attendant  or  friend  sleep  in  the 
room  with  the  patient. 

These  rooms  should  be  fifteen  feet  to  the  ceiling, 
with  one  window  in  the  single  and  two  in  the  double 
rooms,  opening  to  the  outer  air ;  and,  above  the  doors, 
opening  on  the  hall,  there  should  be  a  transom-window. 
The  floors  should  be  similar  to  those  described  in  the 
other  wards,  and  without  car^^ets ;  rugs  should  be  sup- 
plied if  needed,  but  carefully  attended  to  as  to  cleaning. 
The  building  should  have  a  cap-roof  the  width  of  the 
hall,  with  sashes  of  glass  between  it  and  the  main  roof. 
Each  room  should  have  an  open  fireplace  with  foul-air 
shaft  and  ducts,  and  afresh-air  duct  similar  to  that  in  the 
small  ward  described  in  connection  with  the  service-room 
building  of  the  other  wards.  Besides  this,  a  curved  tube 
or  box  could  be  made  to  pass  out  through  the  hall-wall 
and  open  into  the  outside  air  through  a  space  between 
the  cap  and  the  main  roof  The  outside  walls  should 
be  similar  to  those  described  for  the  permanent  pavil- 
ions, but  the  partition-walls  between  the  different  rooms 
and  between  the  hall  and  the  rooms  should  be  made  as 
nearly  as  possible  impermeable  to  air,  for  the  air  dra^\m 
into  a  room  through  these  walls  would  not  be  fresh, 
and  in  some  cases  might  be  very  bad.  The  accommo- 
dation in  such  a  ward  should  be  limited  to  eighteen 
beds.  Therefore  two  detached  pay-wards  and  two  or 
more  special  huts  would  be  needed. 

The  service-room  building  for  a  pay-ward  should  be 
separated  in  the  same  way  and  for  the  same  reasons  as 
in  the  other  buildings.     The  first  floor,  that  on  a  level 


138    PAY-PATIENTS  IN  CHARITABLE  INSTITUTIONS. 

witli  tlie  ward,  sliould  be  divided  by  a  ball  witb  tbe 
water-closets  and  two  batb-rooms  on  one  side,  and  a 
comfortable  dining-room  witb  an  open  fireplace  and  a 
pantry  communicating  witb  tbe  kitcben  by  dumb-waiter, 
and  a  room  for  tbe  nurse  in  cbarge,  on  tbe  otber  side. 

If  bot-water  coils  are  needed,  mstead  of  baving  a 
boiler,  bot  water  could  be  laid  on  from  tbe  administra- 
tive buildings,  as  tbe  pay-wards  sbould  be  not  far  re- 
moved from  tbem.  Hot  water  for  tbe  batbs  and  for 
carrying  to  tlie  rooms  sbould  be  supj)lied  by  tbe  kitcb- 
en-range.  No  pipes  except  gas-pipes,  and  tbese  exposed 
to  sigbt,  sbould  be  laid  on  in  tbe  wards. 

In  tbe  pay-ward,  wbere  tbe  beds  are  in  separate  but 
adjoining  rooms,  witb  a  common  ball,  no  infectious  or 
contao;ious  cases  sbould  be  treated,  and  no  case  liable 
to  become  infected  or  in  any  way  dangerous  to  otbers 
sbould  be  admitted ;  for  in  sucb  a  building,  altbougb 
tbere  are  intervening  walls,  a  case  of  tbe  kind  would  be 
more  dangerous  tban  in  a  building  witbout  partitions. 
Not  tbat  tbe  patient  in  tbe  next  room  is  not  for  a  time 
in  less  danger  of  being  poisoned  tban  be  would  be  if  no 
wall  intervened  ;  but  an  infectious  cage,  or  one  liable  to 
cause  infection,  would  be  more  likely  to  poison  bis  own 
room,  and  tbus  do  more  permanent  injury,  tban  a  simi- 
lar case  in  an  open  ward. 

For  all  infectious  cases,  and  for  treating  all  severe 
and  dangerous  cases  among  tbe  pay-patients,  tbere 
sbould  be  buts  sj^ecially  constructed  for  tbat  purpose. 


i 


CHAPTER    VII. 

SPECIAL  ISOLATED  HUTS  FOE  CERTATN"  LMPOETANT  CASES, 
SUCn  AS  OVAEIOTOMY  ATO)  OTHERS  EXTEEilELY  SEN- 
SITIVE  TO    INFECTIOUS   MATTEE. 

It  would  be  better  if  sucli  cases  were  treated  iu 
every  way  separate  from  a  liosj^ital  in  wliicli  otlier  dis- 
eases are  treated ;  but  a  certain  number  of  sucli  cases 
must  be  admitted  to  liospitals,  and,  unless  special  insti- 
tutions exist  for  tlie  sole  purpose  of  caring  for  tbem, 
they  must  be  provided  for  in  connection  with  general 
hospitals. 

We  will  give  the  plan  of  a  hut  with  special  refer- 
ence to  patients  operated  on  for  ovarian  tumors. 

Ovariotomy  is  one  of  the  most  formidable  of  all 
operations  in  surgery,  and  while  the  operation  is  going 
on  the  largest  serous  membrane  in  the  body  is  exposed 
to  the  air.  This  membrane,  the  surface  of  which  is 
many  times  as  great  as  the  largest  stump  of  an  ampu- 
tated limb,  is  remarkable  for  its  great  susceptibility  to 
ahsorh  septic  poisons.  When  once  inflammation  sets  iu, 
the  great  majority  of  cases  jDrove  fatal.  In  fact,  a  pa- 
tient after  an  operation  for  an  ovarian  tumor  is  the  per- 


140  SPECIAL  ISOLATED  EUTS 

feet  type  of  a  surgical  case  that  is  exquisitely  sensitive 
to  septic  influences.  When  once  infected,  on  account 
of  the  large  surface  and  position  of  the  membrane  in- 
volved, it  seldom  fails  to  generate  and  give  off  sufficient 
poison  to  infect  a  building ;  and,  like  a  case  of  puerj)eral 
fever,  it  renders  the  apartment,  if  not  forever,  at  least 
for  weeks  and  months,  unfit  and  dangerous  for  the  treat- 
ment of  other  cases. 

On  account  of  this  extreme  susceptibility  to  contract 
septic  diseases,  and  the  harm  such  a  case  does  to  the 
building,  it  is  a  direct  violation  of  a  sanitary  lavr,  and  a 
risk  not  only  for  the  individual  patient,  but  to  all  other 
surgical  cases  treated  in  the  building,  for  a  case  of  ova- 
riotomy  to  be  treated  either  in  the  ward  of  a  hospital, 
or  in  a  room  near  the  ward,  particularly  if  that  room  is 
but  a  few  steps  from  the  water-closets  and  bath-room. 
Ko  nurse,  doctor,  or  other  attendant,  who  has  the  care  of 
other  cases,  especially  other  surgical  cases,  should  be  al- 
lowed to  have  charge  of,  handle,  or  come  near,  a  patient 
operated  on  for  an  ovarian  tumor. 

Patients  operated  on  for  ovarian  tumors  should  be 
treated  in  small  one-story  huts,  which  should  contain  at 
most  not  more  than  two  beds,  one  for  the  patient,  the 
other  to  be  used  by  the  nurse  or  attendant  during  con- 
valescence when  the  critical  stage  is  past. 

The  building  should  be  small,  not  only  because  such 
a  building  is  easily  ventilated,  but,  if  it  were  to  become 
infected,  it  could  be  destroyed,  and  a  new  one  erected 
at  a  small  expense. 

There  should  be  two  or  more  huts,  so  that  they 
could  be  used  alternately  and,  when  not  in  use,  be  left 
open  to  the  sun  and  air  for  purification. 


DETAILS  OF  CONSTRUCTIOK 


141 


THE   PLAN    OF   THE   nUT. 

Ground. — The  ground  should  be  covered  mth  a 
layer  of  concrete,  and  asphalted  beneath  and  for  several 


%L 


ISOLATthfc     WooDEhl      MUX", 

A.  ^TOv'e 

B.  ^?«ioi^E  PlJe. 

C?,      ^.\\  Ri/cT^  lii<n)Eii^  Ti-OOFt  Ff^oM  sfrJneF^  "Ben  x<»  ^-[a-^s-.. 

TOWlTl^ltJ  '1  FEE]*  Of  TlOOT^  WIJI^  SCAJTEl^SBO/\l^r»,- 


feet  around  the  building,  and  surrounded  by  an  open 
shallow  gutter  as  a  drain. 


142  SPECIAL  ISOLATED  HUTS 

Position. — As  the  building  is  square,  its  position 
should  be  about  north-nortlieast,  that  is,  tlie  side  toward 
the  north  should  be  about  perpendicular  to  a  line  run- 
ning north-northeast.  In  this  position  the  rays  of  the 
sun  would  reach  all  four  sides  of  the  hut  during  the 
day. 

Dimensions. — The  drawing  represents  a  hut  twenty 
feet  square,  eight  feet  high  to  the  eaves,  and  fourteen 
feet  to  the  ridge  of  the  roof,  which  gives  20  X  20  X  H, 
or  4,400  cubic  feet  of  sj)ace. 

Floor. — The  floor  should  be  of  the  heart  of  Georgia 
yellow  pine,  which  by  nature  is  well  filled  with  resin, 
and  should  be  well  laid  with  tongue  and  groove.  Car- 
penters are  accustomed  to  lay  floors  to  be  covered  with 
carpets,  and,  as  a  rule,  are  not  skilled  in  putting  down 
closely-joined  floors.  The  beams  should  be  sealed  be- 
neath, so  as  to  make  the  floor  double  and  j^rotect  from 
the  cold. 

Height  from  Ground. — The  floor  should  not  be  less 
than  two  feet  from  the  ground.  During  very  severe 
weather,  if  necessary,  the  space  beneath  could  be  closed 
with  glass  sashes.  Locust  posts  make  the  best  under- 
pinning for  tem|)orary  buildings. 

Walls. — Brick  walls  would  make  a  more  substan- 
tial and  for  some  reasons  a  better  building  than  wood. 
If  of  wood,  they  should  be  double,  with  an  air-space 
of  several  inches  between  them,  so  arran2:ed  as  to  be 
opened  at  pleasure  both  at  the  top  and  bottom  on  the 
outside  of  the  building,  but  not  from  the  inside.     This 


DETAILS  OF  CONSTRUCTION.  I43 

would  be  of  im^Dortance  iu  summer.  The  inside  wall 
should  be  closely  joined,  land  planed  and  painted,  or 
polished.  If  the  wall  is  of  brick,  an  air-space  should  be 
left  in  the  centre,  so  arranged  as  to  communicate  with 
the  space  between  the  roof  and  ceiling,  and  to  allow  of 
easy  ventilation  and  fumigation  of  all  these  spaces. 

The  Hoof. — The  roof  should  be  double,  with  an 
air-space  of  several  inches  clear  intervening — not  so 
much  to  keep  out  the  cold  as  to  prevent  overheating 
in  summer.  Tliis  space  should  also  be  made  so  as  to 
be  either  closed  or  opened  from  the  outside.  The  roof 
should  extend  far  enough  beyond  the  walls  to  protect 
them  from  the  weather,  especially  at  the  gable-ends. 

The  Windoios. — The  end-window  facing  the  east, 
and  opposite  the  door,  should  extend  from  within  two 
feet  of  the  floor  and  run  up  as  high  as  the  roof  will 
admit ;  or  there  should  be  a  small  window  above  the 
large  one  arranged  on  hinges  so  as  to  open  at  the  top. 
Besides  this  there  should  be  an  opening  through  the 
end- walls  just  under  the  ridge,  covered  by  a  register,  to 
be  closed  or  opened  at  pleasure.  The  two  side-win- 
dows, commencing  about  the  same  distance  from  the 
floor,  would  necessarily  be  not  more  than  six  feet  high. 
Above  the  door  there  should  be  a  small  window  on 
hinges  similar  to  the  one  above  the  end-window.  All 
the  windoAvs  should  be  not  less  than  three  feet  mde ; 
the  large  end-window  might  be  four  feet  wide,  so  as  to 
give  a  good  light  for  the  operations.  It  would  perhaps 
be  better  to  have  a  northern  light,  but  the  great  major- 
ity of  operations  are  done  in  the  afternoons,  so  that  a 
window  facing  east  would  answer  every  purpose.     The 


14:4:  SPECIAL  ISOLATED  HUTS. 

sashes  should  be  balanced  with  pulleys,  and  be  of  very 
thick  plate-glass  or  double  glazed,  not  double  sashed. 
In  a  temporary  building  everything  must  be  inexpen- 
sive, but  the  glass  of  the  windows  could  be  used  in- 
definitely, and  on  that  account  it  would  not  be  bad 
economy  to  have  thick  plate-glass.  The  w^ood-work 
should  be  j)lain  an cl^  smooth,  and  kept  waxed  and  pol- 
ished. . 

The  Door. — There  should  be  but  one  door,  three 
and  a  half  by  seven  feet,  in  the  end  facing  west.  It 
should  be  wide  enough  to  admit  a  patient  carried  on  an 
ordinary  stretcher.  The  door  should  be  perfectly  plain 
and  without  panels.  During  severe  weather  the  en- 
trance should  be  protected  by  a  closed  framework  with 
a  door  opening  southward. 

Huts  for  ovariotomy  cases  should  not  have  a  nurse's 
room,  but  in  huts  for  chronic  suppurating  wounds,  etc., 
the  nurse's  room  should  be  in  the  northwest  corner, 
eight  by  twelve  feet,  the  long  axis  lying  east  and  west 
so  as  to  include  one  of  the  side- windows.  It  should  be 
separated  from  the  w^ard  by  a  partition,  which  should 
not  be  more  than  seven  feet  high,  with  a  space  of  about 
one  foot  left  open  between  it  and  the  floor,  so  as  to 
allow  a  free  circulation  of  air,  and  room  for  cleansing, 
etc.  This  partition  or  screen  should  be  perfectly  plain 
and  smooth,  without  cracks  and  corners,  and  so  put  up 
that  it  could  be  readily  removed  without  disturbing  the 
building  in  any  way.  It  should  have  a  door  three  by 
six  and  a  half  feet  in  the  free  corner. 

.  Heating. — In  a  temporary  building  of  this  kind  the 
expense  would  be  too  great  to  build  a  chimney  and 


DETAILS  OF  CONSTRUCTIOX.  I45 

have  an  open  fire ;  therefore  a  Franklin  soapstone 
stove,  or  some  kind  of  iron  stove  surrounded  by  a  pro- 
tector, must  be  used,  being  preferable  to  steam-heat, 
even  if  it  were  possible  to  introduce  it  from  other 
buildings.  The  2:)Osition  of  the  stove  should  be  in  the 
northeast  corner,  so  that  the  force  of  the  cold  northeast 
winds  driving  through  the  wall  would  carry  the  heated 
air  to  the  bed  of  the  patient  on  the  south  side  of  the 
room.  By  means  of  a  special  flue  surrounding  and 
heated  by  the  stove-pipe,  the  foul  air  of  the  ward 
should  be  drawn  off.  A  ten  or  twelve  inch  pipe 
inclosing  the  ordinary  six-inch  stove-pipe  would  make 
an  excellent  foul-air  shaft.  In  so  small  a  build  in  o-  a 
stove  will  heat  it  satisfactorily  in  cold  weather,  and, 
unless  the  hut  is  double  roofed,  the  heat  of  summer 
will  give  more  trouble.  The  stove  should  be  an  open 
on«,  of  a  rather  large  size,  and  in  very  cold  climates  the 
stove-pipe  should  not  pass  directly  into  the  foul-air 
shaft,  but  ascend  some  distance  before  enterins;  the 
shaft,  thus  giving  off  more  heat  in  the  ward. 

Ligliting. — The  lighting  must  be  either  by  a  gas-jet, 
or  a  lamp  suspended  near  the  centre ;  the  latter  would 
be  less  expensive.  In  either  case  the  consumed  air 
from  the  light  should  be  conveyed  by  means  of  a  spe- 
cial shaft  or  flue  directly  through  the  roof  into  the  open 
air;  otherwise,  while  burning,  an  ordinary  gas-jet  will 
consume  more  oxygen  and  give  off  more  carbonic-acid 
gas  into  the  ward  than  seven  patients ;  whereas,  if  its 
heated  air  is  conveyed  off  by  a  tube  to  the  open  air,  it 
will  assist  materially  in  ventilating  the  room.  Candles, 
and  not  hand-lamps,  should  be  used  to  su2:)plement  this 
central  light. 
10 


146  SPECIAL  ISOLATED  EUTS. 

Ventilation. — During  tlie  weatlier  not  cold  enough 
to  require  a  fire,  tlie  "building  can  be  readily  ventilated 
by  the  'windows ;  but,  when  the  weather  necessitates 
closino-  the  windows,  other  means  should  be  and  can  be 
easily  arranged  for  drawing  off  the  foul  air.  In  each 
corner  of  the  floor  of  the  room,  three  feet  from  the 
walls,  there  should  be  an  opening  communicating  with 
a  duct  between  the  floors  which  leads  to  the  foul-air 
shaft  of  the  stove  ;  or,  if  there  is  no  special  flue  or  shaft 
in  connection  with  the  stove,  and  separate  from  its  own 
flue,  it  would  be  a  simple  matter  to  so  arrange  it  that 
the  stove  would  draw  all  of  its  drauo;ht  from  these 
ducts.  The  ducts  for  the  huts  for  ovariotomy  cases 
should  be  cast-iron  pipes  similar  to  those  described 
for  the  wards.  In  the  huts  for  infectious  cases  they 
could  be  made  of  boards  eight  or  twelve  inches  wide, 
or  of  tin  pipes  covered  with  straw  packing  to  protect 
from  the  cold  in  case  only  one  floor  is  laid.  The  ojdcu- 
iug  in  the  floor  should  be  not  less  than  ten  or  twelve 
inches  square,  and  protected  by  a  grating,  and  so  ar- 
ranged as  to  catch  dust,  etc.,  in  a  dust-box,  which  could 
be  opened  from  beneath,  and,  if  desirable,  left  open 
during  the  summer ;  yet,  when  malaria  prevails,  all 
fresh  air  shoukl  be  admitted  as  high  from  the  surface 
of  the  ground  as  possible. 

Now,  much  of  the  air  would  come  in  from  the  out- 
side through  unavoidable  crevices  and  directly  through 
the  boards ;  but  this  would  not  be  sufficient ;  and,  in- 
stead of  letting  the  air  iu  by  the  windows,  it  would  be 
better  to  convey  the  cold  air  as  near  the  centre  of  the 
room  as  possible  before  allowing  it  to  scatter.  To  accom- 
plish this,  a  very  simple  means  would  be,  to  have  two 


VENTILATION  OF  THE  HUT.  14 7 

large  sliafts  or  tubes '  pass  through  the  ridge,  projectino- 
above,  and  opening  into  the  air  on  the  outside  and  pro- 
tected by  a  cap ;  on  the  inside  they  should  come  down 
to  the  level  of  the  top  of  the  side-walls,  tliat  is,  seven 
or  eight  feet  from  the  floor,  where  they  should  be  ar- 
ranged so  as  to  be  opened  or  shut  at  pleasure,  but  high 
enough  to  be  out  of  the  reach  of  the  patients;  and  just 
beneath  the  openings  there  should  be  a  scatter-plate  so 
fixed  as  to  cause  the  cold  air  descendino^  to  flare  and 
scatter  through  the  room  and  thus  prevent  draughts  of 
cold  air.  A  large,  ordinary  tin  basin  with  flaring  edges 
swung  beneath  the  end  of  the  shaft  would  answer  as  a 
scatter-plate.  The  shafts  should  be  twelve  by  twelve 
inches  in  diameter,  or,  if  it  is  better  to  have  them  flat 
so  as  to  pass  more  readily  through  the  roof,  they  should 
be  six  by  twenty-four  inches  and  should  pass  through 
the  ridge  on  either  side  three  feet  from  the  centre  of  the 
roof  If  thought  desirable,  two  similar  shafts  can  be 
passed  through  the  ridge  with  no  projections  down  into 
the  ward,  but  opening  near  the  roof  for  the  purpose  of 
carrying  off  the  overheated  air ;  by  means,  however,  of 
the  two  high  openings  in  either  gable  all  overheated 
air  could  easily  be  got  rid  of 

FUEIS^ITUEE. 

Jjeds. — The  beds  should  be  of  cast-iron,  nickel- 
plated,  and  a  little  wider  than  the  usual  hospital- 
bed.  The  mattresses  should  be  of  hair,  and  tliey 
should  be  often  w^ashed  and  disinfected,  and  the  next 
patient  should  have  a  fresh  mattress.  If  wire  mat- 
tresses equally  good  can  be  had,  they  would  be  better 

^  An  account  of  wliicli  lias  aJready  been  given  in  describing  the  fresli-air 
ducts  of  the  wards. 


148  SPECIAL  ISOLATED  EUTS. 

than  hair.  Hair  pillows,  treated  in  the  same  way, 
should  be  used.  The  blankets  should  be  changed  as 
often  as  the  sheets ;  they  are  just  the  things  to  catch 
ors^anic  particles,  and  retain  the'm  till  decomj^osition 
takes  place,  and  thus  poison  the  wound. 

Tables. — A  table  with  a  glass  top,  five  by  two  and 
a  half  feet,  should  be  in  the  ward,  as  it  would  be  needed 
for  operations.  There  should  also  be  a  small  stand  of 
iron  for  the  basins  and  water-vessels.  Water-pipes 
should  not  be  laid  on  in  the  building ;  the  drains 
would  cause  more  danger  than  the  convenience  would 
compensate  for. 

Chairs. — The  chairs  should  be  plain,  with  wooden 
bottoms.  If  a  patient,  while  convalescing,  should  re- 
quire an  easy-chair,  it  should  be  brought  in  for  the 
occasion.  No  cushion  or  anything  of  the  kind  should 
be  allowed  to  remain  in  the  room. 


CHAPTER    VIII. 

ADMINISTEATIVE     BUILDINGS    AND    ARRANGEilENT    OF    THE 
BUILDINGS    ON   THE   GROUNDS. 

Separation  of  the  Ward-Pavilions. — Miss  Niglitin- 
gale  laid  down  the  rule  tliat  "the  distance  between 
the  Mocks  (the  pavilions)  should  not  be  less  than 
double  the  heis-ht  of  the  block."  This  has  been  very 
generally  accepted.  We  do  not  think  this  allows  suf- 
ficient space.  The  distance  between  the  pavilions 
should  not  be  less  than  three  times  the  lieight  of  the 
buildiugs. 

In  the  ward-pavilions  that  we  have  described,  meas- 
urinof  from  the  floor  of  the  ward  to  the  ridcre  of  the 
roof,  the  height  is  about  tweuty-four  feet.  Three  times 
this  wonld  be  seventy-two  feet,  which  we  consider 
should  1)6  the  minimum  of  space  left  between  each 
ward  and  all  other  buildings,  excepting  -its  service-room 
building.  If  the  ground-space  is  suihcient,  we  would 
have  the  distance  between  the  wards  one  hundred  feet. 
If  tramway-carriages  are  used,  the  increased  distance, 
as  it  is  on  a  level,  would  not  make  an  appreciable  dif 
ference. 

The  isolating  huts  for  special  cases  should  also  be 


150  ARRANGEMENT  OF  TEE  BUILDINGS. 

widely  separated  from  eacli  otlier  and  all  other  build- 
ino-s.  Tlie  huts  and  tents  for  infectious  cases  should  be 
widely  separated  and  j)laced  on  the  grounds  in  a  j)osi- 
tion  where  they  would  be  least  likely  to  infect  any 
other  buildings. 

Position  of  tlie  Ward-Pavilions. — The  wards,  with 
their  long  axes  lying  north  and  south,  should  be  ar- 
ranged on  the  southern  exposure  of  the  grounds,  not 
only  to  get  the  sunlight,  but,  in  our  climate,  during  the 
summer  months,  when  the  windows  are  open  to  receive 
the  full  force  of  the  prevailing  w;nds. 

On  one  side  of  the  grounds  should  be  placed  the 
wards  for  men,  on  the  other  the  wards  for  women  and 
children.  The  j)ay- wards  should  be  placed  on  either 
side  of  the  administrative  building,  but  well  separated 
from  it  and  all  other  build in^rs. 


o 


IJie  Administrative  Buildings. — These  should  be 
separate  from  the  vfards,  and  placed  on  that  part  of 
the  ground  where  they  would  not  intercept  the  j)re- 
vailing  summer  winds.  The  northern  side  of  the 
grounds  would  be  the  best  position  for  them  in  our 
American  climate.  The  administrative  or  executive 
building  should  occupy  a  central  position  on  the 
northern  side,  and  have  the  kitchen,  store-rooms,  the 
operating-theatre,  drug-room,-  etc.,  arranged  around  it 
and  connecting  with  the  main  corridor  from  the  wards. 

The  executive  building  should  have  the  reception- 
offices,  the  managers'  room,  the  medical-board  room, 
and  the  superintendent's  office,  on  the  first  floor.  On 
the  second  floor  there  should  be  rooms  for  the  members 
of  the  house-staff;  above  these  should  be  rooms  for  the 


THE  ADMINISTRATIVE  BUILDING.  151 

male  attendauts.     Tlie  basements  could  be  used  for  cer- 
tain stores. 

The  general  kitchen  should  be  placed  in  the  rear  of 
the  executive  building,  convenient  to  the  main  corridor. 
The  kitchen  should  be  supplied  with  all  the  latest  im- 
provements in  cooking-apparatus,  and  should  have  spe- 
cial arrangements  to  prevent  the  flavors  of  all  the  differ- 
ent articles  cooked  from  mixino'.  There  should  be  a 
sj^ecial  diet-kitchen  distinct  from  the  general  kitchen, 
and  under  a  diff^erent  management.  Connected  with 
the  kitchen  there  should  be  well-arranged  store-rooms 
for  vegetables,  meats,  etc. 

Bath-House. — The  general  and  medicated  baths 
should  be  convenient  to  the  main  corridor  and  near 
enough  to  the  kitchen  to  use  tlie  same  boiler-house. 

Tlie  ApotliecarySliop. — The  drugs  for  the  wards 
should  be  in  a  small  buildino;  convenient  to  the  corri- 
dor  and  to  the  operating-theatre. 

Operating  -  Theatre. — The  operating- tlieatre  should 
be.  in  a  separate  building  as  well  ventilated,  and  kept 
as  scrupulously  clean,  as  the  wards.  It  should  have  an 
operating-table  surrounded  by  raised  seats,  with  an 
etherizing-room  and  a  recovqry-room  convenient.  The 
operating-room  should  have  a  good  nortlierii  light.  In 
no  case  should  the  operating-theatre  be  in  the  same 
building  or  even  near  either  the  pathological  rooms  or 
the  dispensary  for  out-door  patients. 

If  the  wounds  are  poisoned  by  the  foul  air  of  an 
operating-theatre  during  an  operation,  the  best-con- 
structed wards  cannot  save  the  i^atients.      One  who 


152  ARRANGEMENT  OF  BUILDINGS. 

is  familiar  witli  either  pathological  rooms  or  the  steam- 
ing stench  of  a  crowded  dispensary  where  all  sorts  of 
people  with  all  kinds  of  disease  are  assembled  will 
readily  appreciate  the  danger  of  having  an  operating, 
theatre  in  or  near  the  same  building.  The  number  of 
seats  in  an  operating-theatre  should  be  limited  to  the 
number  from  which  an  operation  could  be  closely  ob- 
served. It  is  useless  to  have  a  class  of  several  hundred 
students  present  at  an  operation ;  it  is  not  possible  for 
them  to  see  it  to'  any  advantage. 

Accident  -  Ward.  —  Convenient  to  the  ambulance- 
drive  and  to  the  office,  and  near  the  operating-theatre, 
there  should  be  a  small  accident-ward,  Avhere  severe 
cases  could  be  detained  to  receive  immediate  treatment, 
and  where,  if  in  a  dying  condition,  they  should  remain 
instead  of  being  removed  to  a  ward  •  to  die  in  a  few 
hours  and  create  a  disturbance. 

The  Stable. — The  stable  for  the  ambulance-wagons 
and  horses  should  be  on  the  outside  near  the  northeast 
or  northwest  corner  of  the  grounds^  and  should  have 
telegraphic  communication  with  the  offices  in  the  execu- 
tive building.  The  necessary  workshops  for  the  hospi- 
tal should  be  in  the  same  position. 

The  Autojpsy  and  Pathological  Bidlding.  —  The 
2yost-7nortem  and  pathological  building  should  be  in 
either  the  northeast  or  northwest  corner  of  the  grounds, 
and  cut  off  from  the  rest  of  the  grounds  by  a  high  wall 
and  intervening  trees  and  shrubs.  The  attendants 
should  in  every  way  be  separate  from  those  of  the 
wards. 


THE  OUT-DOOR  DISPE2TSART.  153 

The  doctors  in  tlie  liospital,  or  tliose  wlio  visit  the 
wards,  should  never  be  allowed  to  make  a  ^ost-mortem 
examination,  or  even  be  present  when  one  is  made  on 
an  infectious  case.  There  is  always  danger  of  infection 
being  conveyed  to  the  wards  from  a  ])OsUnortem  build- 
ing, and  this  cannot  be  too  carefully  guarded  against. 

The  Out -Door  Dispensary. — The  dispensary-build- 
ing should  be  adjoining  the  grounds  of  the  pathological 
building,  and  should  have  a  separate  entrance  from  that 
of  the  hospital,  with  its  own  attendants  distinct,  both 
medical  and  otherwise,  from  those  of  the  hospital.  If 
it  is  in  or  near  the  executive  building,  the  number  of 
persons  passing  in  and  out  will  create  confusion,  and 
render  discipline  in  the  hospital  more  difficult,  besides 
being  a  constant  source  of  filth  and  dirt,  and  of  infec- 
tious and  contagious  diseases. 

The  buildino-s  for  the  trainino-.school  and  home  of 
the  nurses  should  be  in  one  of  the  corners  of  the  grounds 
nearest  the  executive  building-. 

The  Laundry. — If  convenient  arrangements  could 
be  made,  it  would  be  better  to  have  the  laundry  entirely 
removed  from  the  hospital-grounds,  on  account  of  the 
immense  quantities  of  foul  fumes  necessarily  generated 
and  given  off  from  a  large  laundry.  If  it  is  on  the 
grounds,  it  should  be  on  the  outside,  near  the  corner  on 
which  the  trainin2:-school  buildino;  is  situated. 

The  laundry  should  be  divided  into  not  less  than 
two  parts,  one  for  washing  ordinary  soiled  clothes,  the 
other  for  badly-soiled  clothes.  There  should  also  be  a 
well-arranged  hot-air  chamber  for  disinfecting  purposes, 
and  a  mending-room,  near  the  laundry. 


154  ARRANGEMENT  OF  BUILDINGS. 

As  far  as  j)ossible,  tlie  clothes  sliould  all  be  dried 
out-of-doors  in  tlie  open  air  and  sunlight.  Linen  dried 
in  closed  rooms  not  only  is  not  purified  by  the  open  air 
and  sunlight,  but  in  such  a  room  one  piece  of  linen  not 
well  washed  and  containiug  foul  matter  would  taint  all 
the  others,  and  after  such  a  room  has  been  used  for  some 
time  it  necessarily  becomes  foul,  and  liable  to  infect  any- 
thing that  is  dried  in  it.  In  connection  with  the  laun- 
dry there  should  be  a  drying-yard,  a  part  of  whicli  could 
be  covered  with  a  roof  of  glass  for  use  in  bad  weather. 

The  foul  linen  should  be  brought  twice  a  day  from 
the  wards,  each  ward  liaving  two  large  nickel-plated 
metal  vessels  with  close-fitting  lids :  one  vessel  for  ordi- 
nary linen,  the  other  for  badly-soiled  linen.  These  ves- 
sels should  be  regularly  cleansed  and  disinfected  every 
day,  and  the  one  for  the  foul  linen  should  always  have 
a  disinfecting  fluid  in  it.  Such  a  thing  as  a  "  foul-linen 
shoot"  should  never  exist  either  about  a  hospital  or 
anywhere  else.  We  have  known,  we  are  sorry  to  say, 
of  such  "  shoots  "  made  of  rougli  bricks  and  plaster,  with- 
out any  lining,  being  used  in  a  hospital. 

The  Water -Sii'p'ply. — There  should  be  an  abundant 
supply  of  water  for  the  use  of  the  hospital,  and  a  reser- 
voir for  a  reserve-supply  in  case  of  an  accident  to  the 
usual  source.  The  water-pipes  should  be  made  to  con- 
nect with  eacli  service-room  building  of  the  pavilions, 
and  could  be  laid  along  the  line  of  the  corridors,  but  in 
no  place  should  they  be  laid  near  the  sewer  or  drainage 
pipes. 

Sewers  and  Drainage-Pipes.  —  If  practicable,  the 
hospital  should  have  its  own  sewer-main  leading  direct- 


TEE  SEWAGE  AXD  DRAIXAGE.  I55 

ly  to  tlie  body  of  water  in  wliich  tlie  sewage  of  tlie 
city  empties ;  it  slioulcl  be  made  as  nearly  as  possil)le 
of  impermeable  material  and  well  ventilated,  and  so 
arranged  as  to  prevent  a  rising  tide  from  forcing  back 
the  foul  gases  into  the  drain-pij^es.  On  the  hospital- 
grounds  the  pipes  should  be  impermeable  to  air,  and 
guarded  with  traps.  Each  drain-joipe  should  have  its 
own  trap,  and  each  pavilion  should  have  a  large  trap 
where  its  main  drain  enters  the  sewer.  The  sewers 
should  not  run  under  any  building,  or  near  a  ward,  or 
near  any  of  the  water-pipes. 

The  drain-pipes  from  the  closets,  sinks,  etc.,  should 
not  only  be.  carefully  guarded  with  traps,  but  should 
be  so  constructed  as  to  be  easily  and  completely  exam- 
ined without  tearing  up  any  j^art  of  the  building. 

Special  arrangements  should  be  made  to  simulta- 
neously flush  every  drain-pipe  and  sewer  on  the  hospi- 
tal-grounds once  every  twenty-four  hours. 

Cultivation  of  the  Grounds. — There  should  be  a 
good  supply  of  foliage  on  the  grounds,  not  merely  for 
ornament  or  simply  for  shade,  but  for  its  purifying  in- 
fluence on  the  atmosphere.  Between  the  wards  there 
should  be  grass-plots,  with  slirubs  and  flower-beds  in 
them.  All  space  not  covered  with  grass  or  flowers 
should  be  asphalted. 

In  the  space  between  the  administrative  Imildings 
and  the  wards,  and  between  the  diflerent  sets  of  wards, 
there  should  be  trees  placed  where  they  could  not  inter- 
cept the  sunlight  from  the  wards,  nor  in  any  position 
where  they  would  to  any  great  extent  interrupt  the  free 
circulation  of  air  over  the  grounds.  The  trees  should 
be  carefully  selected  with  regard  to  their  foliage,  which 


156  ARRANGEMENT  OF  BUILDINGS. 

sliould  be  of  a  nature  not  to  make  it  clifBcult  to  keep 
the  grounds  free  from  decaying  vegetable  matter.  All 
the  grounds  should  be  carefully  ke^^t  in  order  by  a 
skillful  gardener. 

The  ^pathological  and  post-mortem  building,  the  sta- 
bles, and  the  laundry,  should  be  cut  off  from  the  rest  of 
the  grounds  by  dense  hedges. 


CHAPTER    IX. 

EELATIOXS    OF   THE    MEDICAL    SCHOOL   AIS^D    THE   TRAINmG- 
SCHOOL    FOR   NURSES   TO    THE   HOSPITAL. 

THE  MEDICAL  SCHOOL. 

Let  us  suppose  tlie  school  to  be  conducted  some- 
vrhat  after  tlie  following  plan  : 

Requirements  for  entering  the  Medical  Scliool. — A 
good  English  education ;  a  good  knowledge  of  mathe- 
matics ;  a  good  knowledge  of  Latin  ;  a  good  knowledge 
of  physics,  especially  chemical  physics. 

After  Admission. — First  Course:  This  course  in- 
clndes  practical  chemistry,  biology,  including  botany, 
anatomy,  a  part  of  physiology,  and  the  use  of  the 
microscope.  To  consist  of  work  in  laboratories  and 
didactic  lectures  to  be  given  in  the  college  buildings 
entirely  separated  from  the  hospital-grounds.  Time 
allowed,  two  years;  but  every  year  there  should  be  a 
rigid  examination.  Those  passing  this  examination 
satisfactorily  should  be  advanced  to  the  second  course. 

Second  Course:"  The  second  course  will  include  spe- 
cial study  of  human  anatomy,  in  the  dissecting-room ; 
physiology  and  pathology,  in  laboratories ;  practical 
pharmacy,  hygiene,  and  sanitary  subjects;  and,  during 


158       MEDICAL  SCHOOL  AND  SCHOOL  FOR  NURSES. 

tlie  second  year  of  tliis  course,  clinical  lectures  and  in- 
struction as  far  as  can  be  given  in  connection  witli  out- 
door patients  of  tlie  dispensary.  During  tins  course, 
all  lectures  and  instructions  should  be  given  in  the 
medical  school  and  dispensary  buildings,  and  not  in 
the  hosj^ital  j^roper.  Time  of  course,  two  years.  But, 
as  in  the  first  course,  more  stress  should  be  laid  upon 
the  ability  to  pass  the  examination  for  the  third  and 
final  course  than  on  the  time  of  study. 

Third  Course:  This  course  will  include  special  study 
of  therapeutics  and  clinical  medicine  and  surgery.  Most 
of  the  lecture  instructions  of  this  course  should  be  driven 
in  the  amphitheatre  and  wards  of  the  hosj^ital. 

If  the  jiathological,  autopsy,  and  other  school  build- 
ings, together  with  the  dispensary  for  the  out-door  pa- 
tients, are  placed  in  one  corner  of  the  grounds,  and 
separated  by  a  higli  wall  from  the  rest  of  the  buildings, 
and  the  students  be  divided  into  classes  somewhat  after 
the  plan  just  given,  the  relations  of  the  medical  school 
with  the  liospital  would,  we  think,  be  much  simplified 
and  made  more  satisfactory  than  by  the  arrangements 
usually  adopted. 

Only  the  advanced  students  of  the  third  or  gradu- 
ating class  would  have  access  to  the  operating-amj^hi- 
theatre  and  the  wards  of  the  hospital.  Thus,  instead 
of  a  class  of  several  hundred  students  of  all  grades, 
creating  a  disturbance  around  the  hospital,  and  cram- 
ming to  its  utmost  the  amphitheatre  to  witness  an 
operation  which  they  do  not  understand — and  which, 
if  they  were  capable  of  appreciating,  on  account  of  the 
crowd,  they  would  be  unable  to  see  or  gain  any  practi- 
cal advantage  from — there  would  be,  if  the  require- 
ments for  attaining  the  third  class  were  such  as  they 


PROFESSORS  AND  STUDENTS.  I59 

should  be,  not  more  than  from  thirty  to  fifty  students 
present  at  the  operations  and  clinical  lectures  in  the 
amphitheatre  of  the  hospital,  and  those  present  would 
not  only  appreciate  but  see  to  advantage  all  that  takes 
place. 

By  means  of  a  special  competitive  examination  open 
to  the  students  who  had  reached  the  second  year  of  the 
iWvd  Qouv Be,  internes  or  house-staff  could  be  selected: 
say,  that  to  every  two  wards,  one  medical,  the  other 
surgical,  a  student  would  be  aj^pointed  to  serve  six 
months  as  junior,  six  months  as  senior,  and  six  months 
as  house  physician  or  surgeon.  This. would  diminish 
the  third  class  by  sixteen  or  twenty  every  year,  and 
those  failing  to  obtain  the  position  of  interne  could 
during  the  last  year  of  the  third  course  be  instructed 
by  the  professors  or  attending  physicians  and  surgeons 
in  the  wards  of  the  hospital. 

The  professors  of  the  first  course  would  have  no  con- 
nection with  the  hospital.  The  professors  and  the  class 
of  the  second  course  would  have  no  connection  with  the 
wards  of  the  hospital,  thus  avoiding  a  great  source  of 
infection,  namely,  that  caused  by  the  medical  and  other 
attendants  of  the  post-mortem  and  pathological  depart- 
ments, who  would  carry  infection  into  the  wards  on 
their  hands  and  in  their  hair  and  clothes.  The  profess- 
ors of  the  third  course  should  be  the  attending  physi- 
cians and  surgeons  to  the  hospital,  and  constitute  the 
medical  board.  In  the  hospital  affairs  they  should  be 
as  a  board  second  in  authority  to  the  trustees  alone. 

The  adoption  of  such  a  system  as  has  been  outlined 
would  not  only  serve  the  best  interests  of  the  students, 
but  those  of  the  patients  also.  It  would  give  the  stu- 
dents the  special  advantage  of  clinical  instruction  in 


160       MEDICAL  SCHOOL  A^^'D  SCHOOL  FOR  NURSES. 

a  mucli  more  satisfactory  manner  than  is  at  present 
afforded  in  tliis  country,  and  it  would  do  away  with 
one  of  the  worst  features  of  medical  schools  abroad, 
namely,  where  they  take  possession  of  a  hospital,  per- 
mitting students  of  all  grades  to  follow  the  attending 
physicians  and  surgeons  in»  their  visits  to  the  wards, 
and  under  the  name  of  dressers  to  assist  in  caring  for 
the  sick. 

AVe  do  not  consider  the  interests  of  the  patients  and 
those  of  the  student  at  all  conflicting.  On  the  contrary, 
Ave  think  that  a  hospital,  so  far  as  the  interests  of  the 
patients  are  concerned,  is  very  much  improved  by  hav- 
ing a  medical  school  attached. 

The  very  presence  of  the  school  insures  a  better  and 
higher  class  of  attending  physicians  and  surgeons  than 
could  be  otherwise  obtained.  The  presence  of  the  stu- 
dents stimulates  the  professor  to  give  his  time  and 
close  attention  to  each  patient ;  and  the  ability  of 
the  house-staff  causes  him  to  be  careful  not  to  make 
mistakes.  His  acts  are  public,  and  subjected  to  severe 
criticism. 

To  make  the  hospital  complete  for  the  interests  of 
the  medical  school  and  of  the  training-school  for  nurses, 
there  should  be  a  lying-in  department,  but  the  best 
authorities  are  decidedly  opposed  to  maternity-wards 
being  connected  with  a  general  hospital.  A  case  of 
puer2:)eral  fever  is  perhaj^s  the  most  infectious  and  dan- 
gerous case  possible,  not  alone  to  other  ]ying-in  women, 
but  to  all  patients  with  open  surgical  wounds ;  and 
there  is  no  question  but  that  the  proximity  of  surgical 
wards  is  sure  to  cause  puerperal  fever  in  lying-in  wards. 

It  would  be  very  desirable  to  have  a  maternity-hos- 
pital established  on  some  other  building-spot  as  remote 


SMALL  RECEPTION-HOSPITALS.  101 

from  tlie  general  hospital  as  convenience  will  allow. 
We  do  not  favor  large  lying-iu  hospitals.  Experience 
teaches  that  any  kind  of  a  home  is  a  safer  place  for  a 
woman  to  be  delivered  in  than  any  hospital,  but  there 
are  a  certain  number  of  cases  that  have  no  homes  and 
must  be  provided  for.  All  the  lying-in  wards  should 
be  small,  containing  not  more  than  from  two  to  six 
beds,  and  the  wards  should  be  in  detached,  one-story 
cottages. 

If  there  is  no  special  building  for  the  treatment  of 
the  eye  and  ear,  the  oculist  should  have  a  room  or 
apartments  well  arranged  with  all  the  necessary  appa- 
ratus, and  a  certain  number  of  beds  assigned  him,  for 
the  treatment  of  eye  and  ear  cases. 


RECEPTION  -  HOSPITALS,  AND  SYSTEM  OF  AMBU- 
LANCES TO  SUPPLY  THE  HOSPITAL  WITH  PA- 
TIENTS AND   INCREASE  ITS  USEFULNESS. 

It  would  be  very  desii'able  to  have  two  or  more 
small  reception-hospitals  established  in  the  city  for  the 
immediate  reception  of  accident  and  other  cases  of  emer- 
gency before  being  removed  to  the  general  hosj^ital. 

These  reception-hospitals  should  contain  not  more 
than  from  four  to  six  beds.  They  should  be  distributed 
in  different  parts  of  the  city  wliere  they  are  most  likely 
to  be  needed.  A  surgeon  (young  men  who  have  had 
hospital  experience  would  be  the  best  suited  for  the 
position)  should  be  in  charge  with  a  nurse  and  an 
orderly  under  him. 

Each  reception-hospital  should  be  connected  by  tele- 
graph with  the  police-stations  in  its  district  and  with 
the  general  hospital,  and  each  should  be  supplied  with 
11 


162        MEDICAL  SCHOOL  AND  SCHOOL  FOR  NURSES. 

an  ambulance,  wliicli  sliould  be  always  in  readiness  to 
start  for  tlie  scene  of  an  accident,  witli  all  the  apj^aratns 
needed  to  care  for  accident-cases  until  tliey  could  be 
transported  to  either  the  general  hospital  or  the  recej:*- 
tion-hospital. 

These  reception-hospitals  serving  as  feeders  to  the 
general  hospital,  would  add  much  to  its  usefulness  and 
keep  it  su];)plied  with  the  most  desirable  cases  for  the 
purpose  of  clinical  instruction. 

The  interest  of  the  municij^al  officers  might  be  en- 
listed in  the  establishment  of  this  system  of  small 
reception-hospitals  and  ambulances,  and  perhaps  they 
might  be  induced  to-  carry  them  on  in  connection  with 
some  public  department  of  the  city;  as,  for  instance,  in 
connection  with  the  police  department,  a  part  of  the 
police-stations  being  used  for  the  hospital.  The  j)lan 
would  not  be  an  expensive  one. 

THE   TRAINING-SCHOOL  FOR  NURSES. 

The  building  for  the  training-school  should  be  in 
the  northwest  corner  of  the  grounds.  It  should  be 
arranged  as  the  home  for  nurses,  where  they  should 
take  their  meals  and  sleep. 

Allowing  one  nurse  to  every  six  patients  for  a  hos- 
pital of  four  hundred  beds,  there  should  be  about  sixty 
nurses  and  student-nurse*s  or  pupils.  To  accommodate 
each  of  these  with  a  separate  room  ten  by  fifteen  feet  in 
size,  the  building  should  be  forty  feet  wide  by  one  hun- 
dred and  fifty  feet  long  and  three  stories  high.  On  the 
first  floor  there  should  be  the  apartments  of  the  superin- 
tendent of  nurses,  a  reception-room,  dining-room,  and  a 
school  or  lecture  room.  On  the  upjier  floors  should 
be  the  dormitories  for  the  nurses,  each  nurse  havinar 


ORGANIZATION  OF  TEE  SCHOOL.  163 

• 

lier  own  room.  The  kitclieii,  batlis,  and  water-closets 
for  this  building  should  be  separated  from  and  con- 
nected with  the  building  by  a  short  corridor,  in  the 
same  manner  as  has  already  been  described  in  the  plan 
for  the  ward  for  pay-patients.  The  dormitories  and 
halls  should  be  constructed  and  ventilated  in  the  same 
way  as  in  the  wards  for  pay-patients. 

There  should  be  a  lady  superintendent  of  nurses ; 
under  her,  a  general  housekeeper,  a  Avoman  to  have 
charge  of  the  linen  and  laundry,  and  one  to  have  charge 
of  the  special  diet-kitchen  and  special  diet-list. 

To  each  ward  of  twenty-four  beds  there  should  be 
a  head-nurse,  and  under  her  control  as  assistants  there 
should  be  a  night-nurse  and  two  or  three  probationers 
or  student-nurses,  and,  when  needed,  a  special  night- 
nurse.  The  hea^l-nurses  on  the  male  side  should  have 
besides  the  above,  under  their  control,  an  orderly  or 
man  assistant. 

The  lady  superintendent  should  have  full  control 
over  all  the  nurses,  should  assign  their  duties,  etc.,  but 
she  and  all  of  the  above-mentioned  assistants  should  be 
under  the  control  of  the  resident  superintendent  of  the 
hospital. 

Besides  the  above  organization,  in  no  way  inter- 
fering, but  working  in  unison  with  it,  there  should  be  a 
school  board  of  instructors  whose  duty  it  would  be  to 
give  lectures  and  special  didactic  instructions  to  the 
student-nurses  during  their  pupilage,  and  to  act  as  an 
examining  board  of  nurses. 

There  should  be  at  least  one  instructor,  a  physician, 
to  teach  the  nurses  what  they  should  know  about  med- 
ical cases  and  the  administration  of  medicines ;  one  to 
teach  them  what    they  should    know  about    surgical 


164        MEDICAL  SCHOOL  AND  SCHOOL  FOR  NURSES. 

cases ;  one  to  give  instructions  on  liygiene  and  sanitary 
subjects,  and  a  skilled  woman  to  teacli  the  cooking  of 
special  diet. 

These  instructors,  with  the  lady  superintendent  and 
one  other  lady — from  a  committee  of  ladies  whom  the 
trustees  of  the  hospital  should  elect  to  inspect  the 
school  and  keep  watch  of  the  nurses  after  graduating 
and  to  see  to  the  general  interests  of  the  school  outside 
of  the  hospital — should  constitute  the  Faculty  of  the 
Training-School  for  Nurses. 

It  would  be  necessary  for  the  instructors  to  prepare 
suitable  text-books  for  the  nurses,  as  there  are  no  good 
ones  in  existence. 

The  students  and  assistant  nurses  can  be  spared 
from  the  wards  in  the  afternoons  and  evenings,  long 
enough  to  give  sufficient  time  for  study  and  recitations. 


CHAPTEK  X. 

IJIPROVEMENT  OF  HOSPITALS  NOW  IX  USsf  SMALL  HOSPI- 
TALS; LYING-IX  hospitals;  HOSPITALS  FOE  COXVA- 
LESCEXTS  ;    AEMY    HOSPITALS  ;    IXSAXE- ASYLUMS. 

There  is  no  immediate  prosj^ect  that  any  of  the 
large  hospitals  now  in  use  will  be  replaced  by  entirely 
new  structures. 

In  the  case  of  public  hospitals  under  the  control  of 
the  State  or  municipal  authorities,  nothing  less  than  a 
political  revolution  brings  about  a  change.  The  in- 
stances are  rare  in  which  the  ravages  of  a  fatal  epi- 
demic give  outsiders  a  chance  to  force  a  change  for  the 
better.  Hospitals  founded  by  individuals  or  by  be- 
quests are,  as  a  rule,  spoiled  in  the  beginning  by  the 
strong  tendency  to  put  up  a  magnificent  monumental 
structure.  So  much  money  is  usually  sunk  in  these 
fine  buildings  that  there  is  nothing  left  to  pay  for  new 
buildings,  and  necessity  comj^els  a  continuance  of  their 
use.  In  all  such  cases  about  the  only  proposal  that  is 
likely  to  meet  with  favor,  so  far  as  impro^dng  the  con- 
struction of  the  hospital  is  concerned,  is  to  have  one  or 
more  detached  wards  for  certain  classes  of  cases  erected 
on  the  grounds  as  far  removed  as  jDossible  from  the  old 
buildings.      Very  often  there  is  no  ground-space  for 


166  SMALL  HOSPITALS. 

sucli  wards,  but  it  is  rarely  tlie  case  that  room  cannot 
be  found  to  put  up  one  or  more  isolating  Luts  and  tlius 
provide  a  place  for  dangerous  cases. 

In  some  cities  there  are  laws  regulating  the  con- 
struction of,  and  the  number  of  lodgers  admitted  into, 
the  lodging-houses,  thus  preventing  the  evils  of  over- 
crowding. With  the  same  end  in  view,  it  would  be 
wise  and  just  for  the  same  authorities  to  enact  a  law,  if 
not  to  regulate  the  construction  of  hospitals,  at  least  to 
regulate  the  iiumber  of  hospital  inmates  in  accordance 
with  not  only  the  cubic  air-space,  but  the  general  hygi- 
enic condition  of  the  atmosj^here.  Thus  managers 
would  be  compelled  to  imj^rove  the  construction  of 
their  hosj)itals  or  make  uj)  for  their  defects  by  limiting 
the  number  of  inmates  in  each  ward.  The  more  faulty 
the  construction,  the  greater  the  cubic  air-space  which 
must  be  allowed  each  patient. 

SMALL  HOSPITALS. 

Hospitals  containing  as  many  as  four  hundred  beds 
must  necessarily  be  comparatively  few  in  number  ;  and 
nearly  all  hospitals,  like  cities,  must  have  small  begin- 
nings. 

In  this  country  the  sick  poor  of  small  towns  and 
country  districts  are  usually  sent  to  the  poor-house  of 
the  county,  and  many  of  these  almshouses  have  no  spe- 
cial accommodations  for  the  sick.  Where  the  number 
of  sick  does  not  exceed  ten  or  twel-ve,  they  could  be 
provided  for  by  the  erection  of  four  or  five  cottages  of 
from  two  to  six  beds  each,  one  or  two  being  reserved 
for  infectious  cases.  The  plan  already  given  for  the 
isolating  huts  could  be  followed  in  building  them. 

In  case  the  number  of  sick  poor  compelled  to  seek 


HOSPITALS  FOR   COUXTRY  TOWNS.  167 

treatment  at  the  liands  of  the  commnnity  exceeds  thir- 
ty, it  would  be  better  to  establish  a  hospital  separate 
from  the  almshouse.  A  small  administrative  buildinf»- 
and  two  wards  of  not  more  than  from  sixteen  to  twenty 
beds  each — one  for  men,  the  other  for  women — supple- 
mented by  several  isolating  huts,  would  be  all  that 
would  be  required.  In  these  small  hos]3itals  none  of 
the  principles  laid  down  for  the  construction  of  the 
larger  liospitals  should  be  violated. 

Hospitals  are  often  established  by  bequests  from 
private  individuals  and,  except  in  our  large  cities,  are 
generally  small.  With  the  growth  of  towns  and  in- 
crease of  population  of  the  country  many  new  hospitals 
will  be  built  in  a  comparatively  short  time ;  not  less 
than  half  a  dozen  j^roposed  new  hospitals  for  a  small 
number  of  beds  have  been  brought  to  our  notice  within 
the  past  two  years.  In  cities  it  will  be  found  that  the 
medical  cases  in  a  general  public  hosj)ital  will  be  to 
the  surgical  cases  as  two  to  one ;  but  in  the  country,  if 
the  well-to-do  class  will  do  their  duty  toward  the  poor, 
the  majority  of  the  sick  poor  can  be  best  cared  for  in 
their  homes,  and  only  those  cases  requiring  special  med- 
ical or  sursfical  skill  and  the  advantas^e  of  trained  and 
constant  nursing  would  be  sent  to  the  hospital,  and  of 
such  cases  the  larger  number  will  be  surgical.  If  the 
children  are  placed  with  the  ,women,  the  accommoda- 
tions for  the  sexes  should  be  about  equal. 

We  will  su^^pose  that  a  careful  canvass  of  the  town 
and  neio;hborino^  districts  has  been  made  to  ascertain 
the  necessity  for  a  hospital  and  the  number  of  beds  re- 
quired to  accommodate  all  the  sick  poor  who  actually 
need  hospital  treatment,  and  that,  as  the  result,  it  has 
been  decided  to  erect  a  hospital  of  seventy-two  beds. 


168  SMALL  HOSPITALS. 

In  establisliing  tlie  new  lios2:)ital,  many  difficulties 
may  be  expected  in  the^vay  of  seeming  a  good  plau. 
The  trustees  are  j^retty  sure  to  be  men  advanced  in 
years,  and  very  natural!}'  take  the  advice  of  men  of 
their  own  age  who  are  connected  with  other  hosj^itals, 
and  consequently  attached  to  the  old  plans  of  construc- 
tion. Besides,  as  the  trustees  have  nev'er  made  a  study 
of  sanitary  matters,  the  strongest  tendency,  and  the  one 
likely  to  influence  their  choice  of  a  j)lan,  will  be  to  put 
up  an  enduring  monument.  If  the  hosj^ital  is  founded 
by  the  generous  benevolence  of  some  private  individual, 
the  trustees  will  consider  it  their  duty  to  see  that  the 
buildings  are  monumental  in  character.  And  this  feel- 
ing will  cause  them  to  favor  those  j)laus  that  mass  the 
different  parts  of  the  hosj^ital  under  one  roof,  and  pile 
the  wards  one  above  the  other. 

The  j^kin  that  masses  all  the  different  parts  of  a  hos- 
pital under  one  roof  is  the  one  that  is  likely  to  please 
the  trustees,  for  it  is  more  in  accordance  with  their 
homes,  their  hotels,  stores,  and  factories.  They  can 
readily  see  and  understand  all  the  j)oints  where  a  plan 
favors  economy  and  convenience  of  administration,  for 
all  theii'  lives  they  have  studied  such  questions  and 
found  that  their  success  depended  uj)on  their  apj^reci- 
ation  and  understanding  of  these  things.  If  they  go 
beyond  this  and  allow  other  considerations  to  influence 
the  plan,  it  is  likely  to  be  in  favor  of  aesthetic  effect, 
and  they  will  in  many  cases  consent  to  a  large  expendi- 
ture of  money  and  permit  encroachments  uj)on  the  eco- 
nomic arrangements  of  the  internal  parts  in  order  to  get 
a  handsome  and  strikino-  buildino;.  On  the  other  hand, 
the  plan  that  aims  at  making  the  healthiness  of  the  hos- 
pital the  first  and  most  important  object  to  be  attained, 


PLAX  FOR  A   SMALL   GENERAL  HOSPITAL.  1G9 

is  objected  to  wlierever  it  seems  to  add  to  tlie  expense, 
interfere  with  the  convenience  of  administration,  or  mar 
the  outside  effect  of  the  buihlings.  The  whole  question 
is  one  of  education.  Lookinsr  at  house-buihlins;  in  a 
broad  sense,  we  find  there  are  four  leading  ideas  that 
determine  the  character  of  a  house  :  First,  to  have  it 
j^rotect  us  from  the  inclemency  of  the  weather ;  second, 
to  have  it  convenient  for  carrying  on  the  necessary  work 
of  life ;  third,  to  have  it  appear  pleasing  to  the  eye ; 
fourth,  to  have  it  healthful.  The  first  belongs  to  all 
ages;  the  second  has  been  more  or  less  perfected;  the 
third,  handed  down  to  us  by  the  Greeks,  is  looked  upon 
as  being  of  the  first  importance  by  architects  and  build- 
ers; the  fourth  belongs  to  the  age  of  Inductive  Science, 
and  is  yet  in  its  infancy. 

The  site  should  be  chosen  with  the  same  care  as  in 
the  case  of  a  large  hospital,  and  with  the  view  that,  in 
time,  it  may  be  necessary  to  increase  the  size  of  the  hos- 
pital, especially  if  the  town  is  a  new  and  growing  one. 
The  hospital  should  be  removed  from  the  centre  of  the 
town,  and  the  grounds  should  be  not  less  than  four 
hundred  by  six  hundred  feet.  If  there  is  a  medical 
school  connected  with  the  hospital,  the  school-buildings, 
dissecting-room,  laboratories,  museum,  and  the  out-door 
dispensary,  should  all  be  on  a  separate  lot  from  the 
hospital-grounds.  In  preparing  the  grounds,  laying 
the  drains,  locating  the  buildings,  and  in  all  matters  of 
construction,  the  principles  already  given  in  the  chapter 
on  "  Construction"  should  be  carried  out. 

The  following  plate  and  description  will  illustrate 
what  we  consider  a  good  plan  for  a  small  general  hos- 
pital : 


170 


SMALL  HOSPITALS. 


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SUGGESTED  PLAN  FOE  A  SMALL  HOSPITAL.       171 


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172  LYIXa-m  HOSPITALS. 

LYING-IN  HOSPITALS. 

Home  is  tlie  best  place  for  tlie  birtli  of  cliildren,  not 
only  on  moral  but  sanitary  grounds. 

Lying-in  ^vards  in  a  general  lios^oital  are  no  longer 
admissible,  and  many  authorities  are  opposed  to  Ijdng-in 
hospitals  of  any  kind. 

For  several  days  after  delivery,  on  account  of  the 
peculiar  condition  of  the  parts,  a  woman  is  exquisitely 
sensitive  to  septic  poison,  and  readily  contracts  a  fatal 
disease.  For  this  reason  it  is  next  to  impossible  to  pre- 
vent the  women  of  an  obstetrical  ward  of  a  general  hos- 
pital from  taking  puerperal  fever.  The  large  amount 
of  discharge  of  decomposing  matter  that  naturally  fol- 
lows the  birth  of  a  child,  although  it  may  not  be  dan- 
gerous to  the  woman  delivered,  will  in  a  few  days,  not- 
withstanding the  greatest  care,  render  the  same  apart- 
ment more  or  less  dansferous  to  other  cases  of  the  same 
kind,  and  the  danger  is  greatly  increased  with  every 
case  delivered  until  puerperal  fever  breaks  out ;  then  it 
is  almost  certain  death  for  the  healthiest  woman  to  be 
delivered  in  the  same  ward  or  in  an  adjoining  aj)art- 
ment. 

It  is  true  that  by  great  care  in  keeping  every- 
thing perfectly  clean  in  and  about  a  lying-in  hospi- 
tal child-bed  fever  may  be  avoided,  but  in  time  the 
dreaded  disease  will  show  itself,  and  one  case  will 
give  off  enough  poison  to  infect  a  whole  building  and 
render  it  dangerous,  at  least  for  a  season,  to  all  cases 
of  delivery. 

A  woman  in  giving  birth  to  a  child  is  safer  even  in 
the  poorest  home  on  a  pile  of  straw,  than  she  would  be 
in  a  hospital-ward  where  there  are  from  ten  to  twenty 


NECESSITY  FOR  LYING-IN  HOSPITALS.  173 

women  witli  new-born  infants,  esj^ecially  if  tliis  ward  is 
in  or  connected  with  a  general  hospital.  When  it  is 
possible  to  give  a  woman  the  necessary  care  during  con- 
finement in  her  home,  it  should  always  be  done  in  pref- 
erence to  sending  her  to  the  best  hospital.  In  a  city 
certain  physicians  and  nurses  should  be  assigned  to  the 
different  districts  for  this  duty. 

In  a  large  city  there  will  always  be  a  certain  num- 
ber of  women  who  must  go  to  some  institution  as  they 
have  no  homes,  and  for  this  class  accommodations  must 
be  provided.  But,  instead  of  being  treated  in  the  wards 
of  a  general  hospital,  these  should  be  placed  in  a  sepa- 
rate institution,  having  a  medical  service  of  its  own — 
both  visiting  and  resident  doctors  and  all  other  attend- 
ants being  held  in  every  way  distinct  from  those  of  any 
other  hospital. 

If  the  poor  even  in  a  very  large  city  are  attended  in 
their  homes,  as  has  been  suggested,  the  lying-in  hospi- 
tal would  not  necessarily  be  very  large ;  under  no  cir- 
cumstances should  it  exceed  one  hundred  beds. 

A  large  lying-in  hosj^ital  offers  excellent  oppor- 
tunities for  giving  students  and  nurses  the  advan- 
tages of  clinical  instruction,  but  assigning  them  to 
attend  cases  in  company  with  the  district  physician 
is  for  many  reasons  a  much  better  means  of  insti'uc- 
tion. 

FLAN  FOR  A   LYING-IN  HOSPITAL.   . 

The  selection  of  the  site  and  the  preparation  of  the 
grounds,  the  construction  of  the  raised  foundations,  and 
all  the  details  of  construction,  should  be  carried  out 
with  the  same  care  we  have  suggested  in  the  plan  for 
the  general  hospital. 


17i  LTING-IY  HOSPITALS. 

By  making  a  few  changes,  tlie  plan  suggested  for  a 
hospital  of  seventy-two  beds  could  be  turned  into  one 
for  a  lying-in  hospital — the  position  and  relation  of 
the  buildings  remaining  as  in  the  plate.  The  huts  and 
cottages,  the  stable  and  dead-house,  should  be  very 
much  the  same.  In  fact,  the  only  important  changes 
to  be  made  would  be  in  the  internal  arrano-ement  of  the 
administrative  and  ward-service  buildino-s  and  in  the 
number  of  beds  to  each  ward. 

In  or  near  the  administrative  buildinsr  there  should 
be  special  accommodations  for  the  waiting  women 
whose  condition  permits  light  work ;  this  Avould  render 
the  wards  less  crowded  and  allow  them  to  be  alter- 
nately vacated  for  cleansing  and  purification. 

The  ward-service  building  should  have  projecting 
from  it  a  special  delivery-ward  which  should  be  cut 
off  from  the  rest  of  the  building  by  a  lobby.  The 
wards  should  contain  not  more  than  eight  beds  each ; 
they  should  be  thirty  feet  wide,  and  allow  twelve  feet 
of  wall-space  to  each  bed ;  in  other  respects  they  should 
be  the  same  as  the  wards  of  the  general  hospital.  They 
should  be  used  alternately,  one  always  being  left  open 
and  exposed  to  the  air ;  when  needed,  they  could  all 
be  used — some  for  those  patients  confined  to  their  beds, 
the  others  for  those  strong  enough  to  sit  up  during  the 
day.  The  jiatients  of  the  latter  class  could  spend  the 
day  in  the  dinincr-room  of  the  service-buildins;  or  in  the 
waiting-ward,  and  thus  allow  their  wards  to  be  left 
open,  during  the  daytime  at  least. 

The  isolating  huts  shown  in  the  plan  would  be  use- 
ful for  infectious  cases,  and  the  special  cottages  would 
serve  for  certain  other  cases  which,  for  good  reasons,  it 
would  be  best  to  keejD  out  of  the  wards.     By  extension 


OUT-OI-TOWX  HOSPITALS.  I75 

of  tlie  main  corridor,  or  covered  way,  tlie  capacity  of 
the  hospital  could  Ijg  increased,  but  the  limit  of  one 
hundred  beds  should  not  be  exceeded.  Such  a  hos2;)i- 
tal  should  be  superintended  by  a  woman — a  lady  both 
by  birth  and  education. 

HOSPITALS  FOR  CONVALESCENTS. 

The  community  which  admits  the  need  of  a  special 
hospital  to  which  the  convalescents  can  be  sent  from  its 
other  hospitals,  virtually  acknowledges  that  its  hospi- 
tals in  use  are  defective. 

AVere  hospitals  built  and  conducted  as  we  have  sug- 
gested, cures  would  be  more  frequent,  prompt,  and  com- 
plete, periods  of  convalescence  would  be  shortened,  and 
such  a  thing  as  a  hospital  for  convalescents,  as  a  sepa- 
rate institution,  would  be  superfluous;  imless,  indeed, 
it  were  situated  on  a  sea-shore  or  on  an  elevation  suf- 
ficiently high  to  give  the  inmates  a  change  of  climate 
or  at  least  a  different  atmosphere,  and  were  used  as  a 
place  to  which  certain  cases  of  special  diseases,  for  the 
successful  treatment  of  which  a  change  of  the  hind  is 
desii-able,  could  be  sent.  Still,  if  the  city  hosj^itals  now 
in  use  are  to  remain  as  they  are,  we  too  should  advo- 
cate the  establishment  of  out-of-town  hospitals  where 
all  cases  that  could  be  removed  from  the  immediate 
care  of  the  doctors  and  nurses  should  be  sent ;  for  we 
are  satisfied  the  complete  recovery  of  convalescents 
would  be  very  much  hastened  by  a  removal  from  the 
necessarily  bad  atmosphere  of  most  of  the  civil  hospi- 
tals that  we  have  seen.  A  hospital  to  supplement 
badly-built  city  hospitals  should  be  located  on  a 
healthy   site   accessible   to   the   city,  but   far   enough 


176  CONVALESCENT  HOSPITALS. 

away  to  give  fresli  air,  and  in  a  neighborhood  where 
land  is  comparatively  cheap,  so  that  the  hos^^ital- 
gronnds  might  include  a  farm  on  which  certain  of  the 
patients  should  labor.  If  a  healthy  sea-shore  or  healthy 
highlands  are  accessible,  they  should  be  j^referred,  for 
the  hospital  could  be  made  useful  not  only  for  conva- 
lescents, but  special  accommodations  could  be  made  for 
a  large  number  of  chronic  cases  that  would  be  greatly 
benefited  l)y  such  a  change.  In  this  climate  (New 
York  City)  such  a  hospital  would  be  of  great  service, 
if  in  connection  with  it  special  arrangements  v/ere 
made  for  giving  the  sick  children  of  the  poorer  classes 
a  few  weeks  of  countrydife  during  the  hot  sumroer 
months  when  the  mortality  among  such  children 
is  so  very  great,  chiefly  owing  to  the  want  of  fresh 
air. 

The  buildings  needed  for  a  convalescent  hospital 
w^ould  be:  an  administrative  building  containing  the 
necessary  offices  and  dwelling-rooms  for  the  superin- 
tendent. Connected  with  this  in  the  rear  should  be  a 
general  kitchen  and  two  dining-rooms,  one  for  each  sex. 
On  either  side  of  this  administrative  buildiniz"  there 
should  be  a  long  row  of  simple  cottages  connected  with 
the  dining-rooms  by  a  coA^ered  way.  These  huts  should 
be  about  twenty-fl.ve  feet  square  and  ten  feet  to  the 
eaves,  with  windows  on  three  sides,  and  should  contain 
four  beds  each.  No  drainage-pipes  should  be  laid  on 
in  these  cottages.  Special  arrangements  at  some  dis- 
tance should  be  made  for  water-closets,  and,  when 
necessary,  earth-closets  could  be  used  in  the  huts.  In 
selecting  the  occupants  for  each  hut,  the  strong  should 
be  put  with  the  weaker  patients  and  compelled  to  take 
care  of  them,  to  a  certain  extent,  by  keeping  their  quar- 


PLANS  FOR  CONVALESCENT  HOSPITALS.  177 

ters  clean,  etc.  If  fuel  is  expensive,  a  system  of  avcU- 
arranged  barracks  might  be  substituted  for  the  separate 
cottages,  but  such  a  hospital  would  be  chiefly  useful 
during  the  seven  months  of  the  year  when  flres  aie  not 
much  needed. 

In  a  well-selected  place  on  the  grounds,  at  least 
two  well-constructed  general  hospital-wards,  after  the 
plans  we  have  given,  should  be  erected  for  the  treat- 
ment of  cases  of  relapse  that  are  likely  to  occur,  and 
for  certain  chronic  cases  that  most  need  the  country 
air. 

A  few  special  isolating  huts  should  be  kept  for  the 
use  of  infectious  cases  that  may  develop.  The  success 
and  usefulness  of  such  an  institution  would,  more  than 
in  one  of  any  other  kind,  be  dependent  upon  the  charac- 
ter and  ability  of  the  superintendent ;  he  should  be  able 
to  judge  character  well,  for  he  must  decide  when  and 
to  what  extent  it  would  be  best  for  the  patient  to 
work;  able,  also,  to  detect  impostors  and  malingerers; 
besides,  his  work,  on  account  of  its  being  removed  some 
distance  from  town,  would  be  less  inspected  than  if  the 
institution  were  more  conveniently  situated.  A  conva- 
lescent hospital  ought  to  cost  comj)aratively  little — 
light  duty  being  required  from  all  patients  who  are 
able  to  perform  it,  not  only  for  the  sake  of  economy 
and  discipline,  but  as  a  curative  measure. 

ARMY  HOSPITALS. 

In  the  case  of  hospitals  connected  with  permanent 
posts,  the  plans  we  have  given  for  civil  hospitals  would 
answer  in  every  resjDect ;  and  even  in  the  event  of  a  war, 
when  hospitals  must  be  hastily  erected  for  the  sick  and 
wounded,  the  same  principles  of  construction  should  be 
12 


178  AEMY  HOSPITALS. 

as  closely  followed  as  tlie  circumstances  of  tlie  case  will 
admit.  ■  Every  nation  going  to  war  should  Lave  on 
hand  or  get  ready  a  large  supply  of  hospital-tents  for 
use  during  summer,  or  whenever  the  season  or  climate 
is  not  too  cold,  and  a  number  of  one-story  wooden  pavil- 
ions constructed  in  j^oi'table  sections  so  arranged  as  to 
be  readily  put  together  for  use.  These  pavilions  could 
consist  of  two  parts,  the  ward  and  the  service-room 
building.  The  number  of  beds  should  be  limited  to 
twenty-eight  to  each  pavilion. 

The  ward  should  be  twenty-eight  feet  wide  by  one 
hundred  and  twenty-six  feet  in  length,  and  twelve  feet 
to  the  ridge  of  the  roof.  The  service-room  building 
should  be  thirty-two  feet  square,  and  divided  in  the 
centre  by  a  hall  with  the  water-closets  or  earth-closets, 
bath-room,  and  servants'  or  nurses'  room  on  one  side, 
and  a  scullery  and  dining  or  mess  room  on  the  other. 
The  connection  with  the  wards  should  be  by  a  short 
corridor. 

The  pavilions  should  be  raised  on  pillars  several 
feet  from  the  ground,  and,  if  there  is  malaria  about,  the 
higher  the  better ;  and  they  should  be  separated  from 
each  other  and  all  other  buildings  by  a  distance  not 
less  than  sixty  feet.  Two  or  more  large  stoves,  as  the 
climate  demands,  will  be  found  the  most  practical  way 
of  warming  temporary  hospitals.  The  experience  of 
our  civil  war  and  the  Franco-German  War,  compared 
with  all  preceding  wars,  shows  conclusively  that  tem- 
porary one-story  wooden  buildings  make  the  best  army- 
hospitals,  and  save  thousands  of  lives  that  would  be 
sure  to  be  lost  if  the  sick  and  wounded  were  treated  in 
any  public  or  private  building  that  is  nearest  at  hand, 
as  was  the  custom  in  former  times. 


HOSPITALS  FOB   TEE  INSANE.  I79 

INSANE-ASYLUMS. 

To  (To  tliis  subject  justice  would  require  mucli  spe- 
cial study,  and  fill  a  volume. 

In  this  country  most  of  our  institutions  are  con- 
structed on  the  massive  monumental  style,  and  man- 
aged on  the  economical,  prison  system,  and  there  is 
still  too  much  of  the  iron  bars,  dark  cells,  and  strait- 
jackets  of  the  old  Bedlam.  Besides,  the  medical  atten- 
tion is  scant  and  necessarily  more  or  less  inefiicient, 
and  the  nursing  is  wretched ;  in  fact,  the  nurses  do 
not  pretend  to  be  anything  more  than  keepers,  and 
the  class  from  which  they  are  selected  is  the  same 
as  that  from  which  keepers  for  criminals  are  derived. 
Uncommon  brute-force  seems  to  be  considered  the 
most  desirable  quality  to  make  a  good  nurse  for  an 
insane-asylum. 

On  Blackwell's  Island,  where  the  largest  charitable 
institutions  of  New  York  City  are  situated,  there  is 
an  insane-asylum  containing  thirteen  hundred  inmates. 
The  large  majority  of  these  are  in  an  old  building  of 
several  stories,  with  wards  for  forty  or  fifty  2:>atients 
each ;  with  the  exception  of  the  raving  maniacs  that  are 
in  a  badly-constructed  lodge,  the  rest  of  the  patients 
are  in  cheap  one-story  wooden  pavilions.  At  the  pres- 
ent time  the  whole  institution  is  under  the  control  of 
one  paid  medical  oificer,  who  sometimes  has  two  or 
three  voluntary  medical  assistants,  and  sometimes  is 
entirely  alone  and  is  expected  to  render  medical  assist- 
ance to  all  the  patients,  and  at  the  same  time  act  as 
suj^erintendent  or  executive  officer. 

At  the  time  of  our  visit  the  doctor  informed  us  that 
he  had  no  hold  on  his  assistants,  and  could  never  be 


180  INSANE-ASYLUMS. 

sure  how  long  tliey  would  remaiu  with  him.  There 
was  in  the  whole  hos^^ital  one  nurse  to  every  twenty- 
eight  patients.  In  one  of  the  wards  intended  for  forty 
we  found  ninety-three  patients,  and  only  two  nurses  in 
charge. 

On  the  same  island,  at  Charity  Hospital,  where 
there  are  usually  one  thousand  patients,  there  are,  be- 
sides a  medical  executive  officer,  a  house  staff  of  twenty- 
four  and  a  visiting  staff  of  twenty-seven  medical  men, 
or  about  one  doctor  to  every  eighteen  patients ;  while 
at  the  insane-asylum,  allowing  the  physician  two  assist- 
ants, there  is  only  one  doctor  to  four  hundred  and 
twenty-five  paii^ents! 

The  above  account  would  not  fairly  represent  the 
condition  of  all  our  insane-asylums;  but,  even  in  our 
best  institutions  for  the  insane,  it  will  be  found  that 
there  are  several  hundred  patients  to  each  physician, 
and  the  nurses  too  few  in  number  and  not  above  the 
grade  of  common  household  servants.  Some  of  the 
buildings  are  magnificent  structures  put  up  at  the  cost 
of  millions  of  dollars,  but,  in  our  opinion,  in  many 
respects  unsuited  for  the  purpose  they  are  intended 
to  fulfill. 

Of  course,  dangerous  maniacs  and  raving,  acute, 
insane  patients  must  have  special  arrangements  for 
their  care ;  but  the  large  majority  of  the  insane  can 
be  treated  very  much  as  rational  beings,  and  well- 
trained,  reliable  nurses  in  sufficient  number  would 
render  unnecessary  large  wards  and  close  confinement, 
and  enable  most  of  the  patients  to  be  kept  under 
agreeable  and  natural  conditions  conducive  to  their 
recovery.  And  if  some  of  the  money  expended  in 
fine  buildings  was  used  to  pay  the  best  medical  talent 


FAULTS  OF  OUR  ASYLUMS.  181 

to   devote  their  time    to  the  study  and  care  of  the 
insane,  the  results  would  be  much  more  satisfactory. 

More  than  any  other  class  of  patients,  the  insane 
are  influenced  l>y  external  conditions  that  surround 
them,  and  that  institution  is  the  best  which  brings 
its  patients  under  conditions  that  make  the  nearest 
approach  to  a  cheerful  and  comfortable  home. 


CHAPTEE    XI. 

HOSPITAL-BUILDINGS    NOW   IN    USE. 

Houses  can  be  classified  according  to  their  different 
plans,  perhaps  not  so  definitely  and  accurately  as  a 
naturalist  can  arrange  the  different  ty23es  of  animals  or 
2:)lants,  but  as  readily  and  understandingly  as  can  be 
done  with  the  other  works  of  man.  In  studying  over 
and  in  grouping  the  buildings  now  in  use  as  hospitals, 
we  find  many  old  structures  that  can  be  very  aj^pro- 
priately  called  old  fossils,  and  that,  judged  by  their 
past  history,  are  truly  comparable  to  the  largest  and 
the  most  destructive  of  the  ichthyosaurians  of  past 
a£:es. 

Our  limited  knowledge  of  the  hospitals  of  Indiai* 
compels  us  to  confine  our  remarks  to  those  of  Europe 
and  America.  We  will  use,  for  the  pui'pose  of  illustra- 
tion, chiefly  those  hospitals  which  we  have  had  the 
opportunity  of  visiting  in  person. 

AYe  recognize  five  distinct  types  in  those  now  exist- 
ing: 

*   1.  The  Old  Conglomerate,  including  all   extempo- 
rized and  iiTegular  hospitals. 

2.  The  Old  Block  Plan. 

3.  The  Corridor  Plan. 


OLD  HOSPITALS  OF  PARIS  183 

4.  The  Pavilion  System. 

5,  The  One-Story  Pavilion  Plan. 

THE   OLD   CONGLOMERATE. 

Unless  the  early  Chi'istians  borrowed  the  ideas  and 
adopted  the  plans  of  the  hospitals  used  hy  the  ancient 
fire- worshipers — of  which  we  have  no  evidence — it  is 
probable  that  the  first  hospitals  of  Europe  were  certain 
rooms  in  or  near  the  monasteries  and  convents,  and 
were  inere  appendages  to  those  institutions.  During 
the  middle  ages  the  monks  and  members  of  the  reli- 
gious brotherhoods  were  about  the  only  class  who 
understood  medicine,  and  it  is  likely  that  the  monks 
and  priests  distributed  medicine  and  gave  advice 
very  much  in  the  same  way  as  is  done  to-day  by  our 
out-door  dispensaries.  It  is  certain  that  they  often 
accommodated  the  sick  in  or  near  their  monasteries 
and  churches.  From  such  beginnings  some  of  the  most 
famous  hospitals  in  the  world  have  grown.  Of  this 
class  the  renowned  old  Hotel-Dieu  of  Paris  is  the  most 
illustrious  examj^le.  This  immense  old  structure  stood 
on  both  banks  of  the  Seine,  with  connecting  portions 
lying  across  and  others  running  under  the  stream,  and 
only  a  few  steps  from  the  cathedral  of  Notre-Dame. 
When  we  visited  it  five  years  ago  the  wards  were  filled 
with  patients,  and  in  more  ways  than  one  it  reminded 
us  of  an  old,  gnarly,  weather-beaten  oak  with  a  decay- 
ing, rotten  centre.  Its  different  j)arts  were  shaped  and 
arranged  with  about  as  little  uniformity  and  evident 
order  as  the  branches  of  an  old  oak,  and  its  wards  were 
about  as  fit  places  for  the  sick  to  inhabit  as  the  cavities 
of  a  decaying  tree  would  be  for  man  to  live  in.  It  was 
founded  aboi^  the  beginning  of  the  seventh  century  by 


IS4:  OLD  HOSPITALS  OF  PARIS 

St.  Landry,  Bisliop  of  Paris,  and  grew  to  an  immense 
size ;  a  century  ago  it  contained  several  thousand  beds 
and  from  two  to  six  patients  to  eacli  bed.  Early  in  tlie 
sixteenth  century  the  beds  were  still  larger,  having  from 
eight  to  twelve  patients  in  each,  and  dui'ing  the  preva- 
lence of  the  plague  as  many  as  sixty-eight  thousand 
died  within  the  hospital  in  one  year.  Although  it  was 
utterly  condemned  more  than  a  hundred  years  ago,  it 
was  in  use  as  a  hospital  until  within  the  past  few 
years.  Fortunately,  there  is  not  such  another  example, 
but  there  are  many  hospitals  that  can  claim  to  be  lesser 
evils  only  on  account  of  their  smaller  size. 

La  Cliarite  was  originally  an  old  chapter-house. 
In  1637  it  was  enlarged  and  turned  into  a  hospital,  and 
now  contains  about  four  hundred  beds.  St.-Antoine 
was  an  old  convent  opened  as  a  hospital  in  1795.  In 
1862  it  was  enlarged  in  a  quadrilateral  form,  and  now 
holds  four  hundred  and  eighty  beds.  Beaujon^  once  an 
orphan- asylum,  was  also  converted  into  a  hospital  in 
1795.  In  1844  new  pavilions  were  added,  making  the 
hospital  surround  a  square  yard.  Several  of  the  other 
hospitals  of  Paris  were  old  convent-buildings,  and  have 
not  been  very  much  altered. 

In  this  country  and  in  England  the  early  history  of 
our  hospitals  shows  the  source  of  some  of  our  faulty 
hospital-.buildings.  After  it  has  been  decided  that  a 
hospital  is  needed,  before  the  managers  or  authorities 
are  prepared  to  build,  either  from  the  want  of  funds  or 
the  necessity  of  the  case,  some  old  private  dwelling  or 
public  building  is  hastily  fitted  up  and  used  as  a  hos- 
pital ;  and  finally,  instead  of  putting  up  a  new  building, 
the  extemporized  hospital  is  enlarged  by  changes  and 
additions  and  indefinitely  continued  as  a  l^spital.    Such 


EXTEMPORIZED  HOSPITALS. 


185 


buildings  make  very  bad  liospitals,  and  it  is  false  econ- 
omy to  use  any  old  building,  however  much  improved 
by  additions  and  changes,  for  the  purpose  of  treatino- 
the  sick  any  longer  than  absolute  necessity  compels. 
The  2^1ainest  temporary  Trooden  shanties  are  preferable. 


Fig.  1. 


•  HopiTAL   Neckek. 

A,  wards ;  B,  chapel ;  C,  corridor ;  D,  pharmacy ;  E,  offices ;  F,  dwelUng ; 
G,  kitchen. 

As  examples  of  extemporized  hospitals  of  the  old 
conglomerate  class  we  take  the  following :  Fig.  1  gives 
tracings  of  the  ground-plan  of  the  Hopital  Necke)\  of 
Paris,  originally  a  Benedictine  monasteiy,  which  was 
enlarged  and  turned  into  a  hospital  of  one  hundred  and 
twenty  beds,  in  1776.     In  1862  it  was  further  enlarged 


186 


OLD  CONGLOMERATE  HOSPITALS. 


by  additions,  and  now  contains  tliree  hundred  and 
eighty-six  beds.  There  are  three  stories  of  wards,  and 
the  buildings  containing  them  surround  three  sides  of 
a  square  court,  the  fourth  side  being  occupied  by  a  gal- 
lery.    The  larger  wards  contain  twenty  beds,  and*the 


Fig.  2. 


tL.ly. 


VJ 


w 
t»_ 


tit---4Li 


%' 


\A/  I 


Bellevce  Hospital,  of  Xew  Toue. 


C,  C,  C. 

D,  E,  F,  G,  n. 
W,  W,  W,  etc. 
a,  a,  a,  etc. 

c  and  b. 

d. 

e  and  g.     ♦ 

h. 


Courts. 

OfSces,  etc. 

Wards. 

Water-closets. 

Xurses'  Rooms. 

Laundry. 

Heating-apparatus. 

Kitchen. 


[3HJ 


I 


smaller  six  beds  each.  The  nurses'  rooms  are  between 
wards,  and  the  closets  and  baths  at  the  ends  of  the 
bull  din  o-s. 

Fig.  2  represents  the  first  floor  of  Bellevue  Hospital, 
of  New  York  City.  Two-thirds  of  the  present  building 
now  used  as  a  hospital  was  originally  an  almshouse  and 
penitentiary,  built  1811-16.  At  first  only  a  small  por- 
tion was  used  for  hos23ital  purj^oses,  but  dui'ing  epi- 


I 


BELLEYUE  HOSPITAL.  157 


demies  of  ty]:)]ius  fever  and  other  diseases,  and  as  tlie 
city  grew  larger,  it  became  more  of  a  liospital.  In 
18-48  tlie  almshouse  and  penitentiary  inmates  "were 
removed  and  a  regular  medical  board  organized,  and 
the  whole  building  was  used  as  a  hospital.  In  1857 
the  hospital  was  so  crowded  that  the  garrets  were  used 
as  wards,  and  it  became  a  necessity  to  enlarge  the  build- 
ing. From  1857  to  1860  renovations  were  going  on: 
partitions  which  ran  lengthwise  in  the  buildings  were 
cut  into  arches,  the  windows  enlarged,  and  on  the  old 
portion  a  third  story  was  added  and  a  new  wing  built 
on  the  northeast,  which  is  a  mere  extension  directly 
connected  with  and  on  precisely  the  same  plan  as  the 
old  almshouse  portion. 

From  1860  to  1873  the  hos23ital  usually  contained 
from  seven  to  eight  hundred  patients,  and  during  each 
year  from  seven  to  eight  thousand  patients  were  ad- 
mitted. Several  wards  were  used  for  lying-in  cases, 
and  from  four  to  five  hundred  women  were  delivered 
annually.  Of  the  seven  or  eight  thousand  admitted  on 
an  average,  more  than  one  thousand  died  in  the  hospi- 
tal, making  a  mortality  of  one  in  every  seven  or  eight, 
or  about 'twelve  and  a  half  per  cent,  of  all  the  patients 
admitted.  During  successive  years  in  the  printed  re- 
ports of  the  hospital,  from  sixty  to  seventy  deaths  are 
reported  as  being  caused  by  pyaemia  and  puerperal  fever 
alone,  which  is  more  than  six  per  cent,  of  all  the  deaths. 
From  time  to  time  efforts  to  imj)rove  the  hospital  were 
made  by  members  of  the  medical  board ;  the  fever  and 
contagious  cases  were  removed  and  placed  in  temporary 
one-story  wooden  pavilions  on  BlackweU's  Island,  and  a 
pavilion- ward  was  erected  on  the  grounds  for  erysipelas 
and  other  infectious  cases.     In  1874  a  move  was  made 


188  OLD   CONGLOMERATE  HOSPITALS. 

by  tlie  State  Charities  Aid  Association  to  improve  the 
hospital,  on  account  of  the  excessive  mortality,  esj^ecially 
among  the  acute  surgical  and  maternity  cases,  which 
was  obviously  caused  by  the  faulty  sanitary  condition 
and  construction  of  the  buildincr.  Althou2:h  this  move 
did  not  effect  satisfactorily  the  object  aimed  at,  still,  it 
was  the  means  of  doing  good,  for,  during  a  fearful  epi- 
demic of  puerperal  fever  in  the  maternity- wards  when 
the  death-rate  was  two  out  of  every  five  of  the  women 
delivered,  the  lying-in  cases  were  all  removed  and  the 
maternity-service  in  the  hospital  was  done  away  with 
altogether.  Since  then  the  number  of  j)atients  in  the 
surgical  wards  has  been  diminished,  and  a  system  of 
artificial  ventilation  has  been  introduced.  This  venti- 
lating apparatus  has  j)roved  to  be  an  utter  failure.  At 
present  the  hospital  consists  of  a  central  administrative 
part,  with  wings  on  either  side,  three  stories  high,  fifty 
feet  wide,  rectangular  in  shape,  and  cut  up  into  wards 
by  partition  walls,  through  which  doors  open  dii^ectly 
from  one  ward  to  another,  while  between  the  wards  are 
the  badly-drained  bath-rooms  and  water-closets,  with  no 
openings  except  directly  into  the  wards.  Joined  direct- 
ly to  these  wings,  with  only  a  narrow  staircase  inter- 
vening in  the  j^assage,  are  the  north  and  south  portions 
of  the  building,  which  are  also  three  stories  high,  and 
are  divided  into  wards  and  arranged  in  exactly  the 
same  manner  as  the  central  part,  as  will  be  seen  by  the 
diagram  ;  some  of  the  wards  for  twenty  beds  have  only 
six  windows. 

Charity  Hospital^  of  this  city,  built  by  the  munici- 
pal authorities  as  late  as  1860,  is  a  massive  stone  struct- 
ure, several  stories  high,  and  contains  usually  more  than 
a  thousand  patients  under  one  roof.     The  wards  are 


IRREGULAB^  UOSPITALS. 


189 


not  unlike  tliose  of  Bellevue,  Laving  tlieir  long  axis 
running  across  the  building,  thus  causing  tlie  dis- 
tance between  opposite  windows  to  be  veiy  great, 
and  making  it  necessary  to  place  the  beds  along  tbe 
partition-walls,  between  whicli  are  tke  water-closets, 
baths,  etc. 

L'regular  hospitals  of  the  conglomerate  class  are 
veiy  numerous,  and  include  many  famous  hospitals. 
With  the  exception  of  the  new  St.  Thomas's,  all  the 
important  hospitals  of  London  can  be  classed  under 
this  head.  Also  many  hospitals  on  the  Continent,  and 
all  hospitals  in  this  country  built  previous  to  1860, 
except  those  that  we  will  mention  hereafter,  must  be 


Fig.  3. 


King's  College  Hospital,  London. 


included.  Fig.  3  represents  one  of  the  floors  of  King's 
College  Hospital^  of  London.  It  is  a  good  example  of 
the  irregular  class.  The  building  is  comparatively  of  a 
recent  date,  put  up  since  1850,  and  crowded  into  a 
small  space  near  the  Eoyal  College  of  Surgeons,  the 


190  OLD   CONQLOMERJLTE  HOSPITALS. 

object  being  to  have  a  liospital  convenient  to  the  col- 
lege, wbile  the  evident  aim  of  the  architect  was  to 
get  in  as  many  beds  as  jDossible.  It  is  a  four-story 
building  witli  an  attic,  and  contains  one  hundred  and 
fifty  beds.  The  large  ward  shown  in  the  diagram  illus- 
trates a  double  Avard  with  four  rows  of  beds  between 
opposite  windows,  a  very  objectionable  plan,  but,  as 
will  be  seen  by  the  following  examples  of  the  London 
hospitals,  a  style  that  has  been  very  generally  adopted. 
St.  Bai'tJiolomeio's  is  the  oldest  of  London  hospitals  ;  it 
dates  back  to  1102.  It  was  rebuilt  in  1730.  Most  of 
the  wards  are  in  three  separate  buildings  four  stories  in 
height,  with  two  wards  on  each  floor.  The  wards  are 
divided  by  a  partition,  and  have  four  rows  of  beds  be- 
tween the  windows. 

Guy's  Hospital  was  founded  in  1722.  The  old 
building  surrounds  two  small  courts,  with  extensions 
inclosing  three  sides  of  a  larger  square  in  the  rear.  A 
new  building  contains  two  large  w^ards  on  a  floor,  with 
four  rows  of  beds  between  the  windows,  and  divided  by 
a  partition  similar  to  those  of  St.  Bartholomew's. 

London  Hospital^  built  in  1740,  reminded  us  very 
much  of  Bellevue ;  it  is  of  the  same  shape,  and,  being 
in  the  east  end  of  London,  receives  the  poorest  class  of 
patients;  most  of  the  wards  are  divided  by  a  partition- 
wall  as  at  Bellevue,  and  have  four  rows  of  beds  between 
the  windows. 

Middlesex  Hospital  is  on  the  block  plan,  and  shaped 
like  the  letter  H. 

GTiaring-Oross  is  a  solid  building  several  stories 
high,  and  contains  one  hundred  and  eighteen  beds. 
The  wards  are  almost  square,  and  open  directly  into 
each  other. 


GERMAN  HOSPITALS. 


191 


University  College  Hospital  is  something  like  the 
regular  old  block  plan,  but  must  also  be  classed  as  an 


Fig.  4. 


AlLGEMEINE    KkANKEXHAUS,    of    YlKNXA. 

Tracings  representing  the  ground-plan  of  the  building.     The  partitions  dividing  the 
buildings  into  wards  are  not  given  in  the  drawing. 

irregular  conglomerate  hospital.  All  other  English 
hospitals  built  previous  to  1860,  with  which  we  are 
acquainted,  are  either  irregular  as  the  above,  or  slightly 


192  OLD   CONGLOMERATE  HOSPITALS. 

modified,  but  by  no  means  improved,  by  having  por- 
tions on  tlie  corridor  plan. 

Fig.  4  gives  tracings  representing  tlie  ground-pl^n 
of  tlie  Vienna  General  Hospital.  The  partitions  divid- 
ing the  buildings  into  wards,  etc.,  are  not  given  in  the 
diagram.  As  the  wards  have  opposite  windows  and 
only  two  rows  of  beds,  it  might  have  been  classed 
under  the  old  block  plan  ;  but  it  is  also  very  irregular 
and  faulty.  This  hospital  was  established  by  the  Em- 
peror Joseph  II.,  in  1784.  It  has  accommodations  for 
three  thousand  patients,  and  usually  contains  as  many 
as  two  thousand  inmates.  The  wards  are  constructed 
on  the  old  block  plan  and  are  in  buildings  two  stories 
high,  which,  as  is  shown  by  the  diagram,  surround  nine 
different  squares  or  courts  that  serve  as  airing-grounds 
for  the  patients.  There  are  in  all  ninety-three  wards, 
of  different  sizes.  The  service-rooms  are  built,  as  in 
Bellevue  Hospital,  between  the  ends  of  the  wards ;  the 
windows  are  opposite,  but  placed  so  high  that  the 
patients  cannot  look  out  of  them.  There  are  four  am- 
phitheatres, two  dispensaries,  two  kitchens,  and  many 
offices. 

Munich  General  Hospital^  founded  in  1808,  is  on 
the  same  plan ;  it  contains  live  hundred  beds,  and  is 
built  around  three  courts,  two  large  and  one  small  one. 
But  almost  all  the  old  hospitals  of  Germany  are  on  the 
corridor  plan. 

Most  of  the  hospitals  of  Italy  are  old,  irregular 
buildings.  0ne  of  the  oldest,  opened  1456,  is  one  of  * 
the  monuments  of  the  middle  ages,  to  which  we  have 
already  alluded  in  Chapter  I.  It  has  fifty-six  wards, 
arranged  for  over  three  thousand  beds.  Fig.  5  gives 
the  outlines  of  the  ground-plan.     The  two  large  crosses 


GEAND  HOSPITAL   OF  MILAN: 


193 


^L-±-Ji^ 

1^       1" 
1       •■ 

"     L 
1 

•8- 
f 

— _— -n 
J 

3       n 


13 


194  TEE  OLD  BLOCK  FLAK 

represent  tlie  main  buildings.  In  tlie  centre  of  tlie 
cross  is  an  altar  for  holding  divine  services.  The  ceil- 
ings of  the  wards  are  from  thirty  to  forty  feet  high. 
Corridors  run  along  both  sides  of  the  wards,  and  the 
windows  are  placed  above  them.  The  outside  wards, 
completely  inclosing  the  courts,  are  not  so  high,  and 
were  evidently  added  later. 

St.  Louis  Hospital^  at  Turin,  was  originally  a  palace, 
built  1794,  and  afterward  turned  into  a  hospital.  It  is 
a  two-story  Greek  cross,  with  a  chapel  in  the  centre,  into 
which  the  wards  open. 

The  General  Hospital  of  Madrid  is  an  immense 
quadrangular  building,  several  stories  high,  begun  in 
1788,  and  now  has  sixteen  hundred  and  twenty-one 
beds. 

The  hospitals  of  the  conglomerate  class  have  all  the 
faults  of  the  old  block  plan,  and  are  still  used  as  hospi- 
tals either  through  ignorance  or  indifference  as  to  what 
is  required  for  the  proper  care  of  the  sick. 

THE   OLD   BLOCK   PLAN. 

The  hos]3itals  of  this  plan  usually  consist  of  a  solid 
building  several  stories  high,  the  central  part  being- 
used  for  offices  and  administration-rooms,  with  wards 
in  wings  on  either  side.  When  the  hosj)ital  is  a  large 
one,  the  buildings  extend  more  or  less  around  a  court- 
yard, and  in  som^  cases  around  two  or  more  court- 
yards. 

The  evident  design  in  adoj^ting  such  a  plan  seems 
to  be  to  save  ground-space,  make  the  administration 
economical,  and  at  the  same  time  establish"  an  imposing 
and  endurino;  monument.      As  a  rule,  manao-ers  and 


ROYAL  mFIRMARY  OF  EDINBURGH.  195 

arcliitects  have  a  strong,  in  fact  an  almost  irresistible 
predilection  for  such  plans. 

The  old  Royal  Infirmarij.,  of  Edinburgh,  was  one  of 
the  first  hospitals  regularly  designed  and  built  on  the 
block  plan.  The  history  of  the  establishment  of  this 
hospital,  as  related  in  a  small  volume  published  in  1778, 
is  strikingly  like  the  history  of  many  of  our  first  hospi- 
tals, and  the  plan  of  the  buildings  so  similar  that  it  is 
evident  the  Eoyal  Infirmary  is  the  original  model  from 
which  the  rules  and  regulations  and  the  style  of  build- 
ings have  been  derived.  The  following  account,  to- 
gether with  the  diagram,  was  taken  from  the  volume 
referred  to  above : 

"In  the  year  1725  the  Royal  College  of  Physicians, 
who  had  long  given  gratuitous  advice  and  medicines  to 
the  sick  poor  at  their  hall,  being  thus  well  acquainted 
with  their  miserable  state,  undertook  to  obtain  sub- 
scriptions for  such  a  fund ;  and,  as  a  good  example  to 
others,  were  the  first  subscribers,  and  engaged  to  attend 
the  infirmary  regularly  in  their  turns  without  fee  or 
reward.  .  .  .  The  subscription  of  two  thousand  j^ounds 
was  no  sooner  completed,  than  the  College  of  Physicians 
called  the  contributors  together,  who  named  twelve  of 
their  number  as  a  committee  for  collecting  the  money 
subscribed,  for  obtaining  more  subscriptions,  and  for 
preparing  a  plan  of  management  of  the  infirmary.  .  .  . 
This  committee,  having  received  as  much  money  as,  by 
its  annual  rent,  might  maintain  a  few  patients,  and 
having  prepared  a  report  concerning  the  management 
of  the  hospital,  called  a  meeting  of  contributors,  where 
twenty  managers  were  elected,  and  such  regulations  as 
were  then  deemed  necessary  were  digested  and  ordered 
to  be  printed;  and  on  the  6th  of  August,  1729,  a  small 


196  ROYAL  INFIRMARY  OF  EDIKBURGH. 

hired  house  Avas  opened  for  receiving  sick  poor.  .  .  . 
After  several  years  of  trial  of  the  good  effects  of  this 
in&mary,  the  managers  represented  the  advantages  of 
such  a  hosj^ital  in  an  humble  petition  to  his  majesty, 
who  was  graciously  pleased  to  grant  a  charter,  dated 
the  25th  of  August,  1736." 

The  charter  being  granted,  it  was  decided  to  build  a 
new  hospital,  and  the  foundation  for  half  the  building 
was  laid  in  1738.  Fig.  6  represents  the  second  floor. 
The  book  before  us  contains  drawings  of  each  floor,  and 
in  the  text  is  a  full  description.  In  describing  the 
building,  which  stands  in  four  acres,  the  writer  says : 

"  This  house  consists  of  a  body  and  two  wings,  each 
of  three  full  stories,  and  an  attic  one,  with  garrets 
above.  .  .  .  The  body  of  the  house  is  two  hundred 
and  ten  feet  in  length  ;  from  each  end  of  which,  and  at 
right  angles,  a  wing  is  extended  seventy  feet,  having 
vaulted  cellars  below.  The  middle  of  the  body  is 
thirty-six  feet  wide,  but  the  rest  of  the  house  is  only 
twenty-sixty  feet  wide.  ...  In  the  middle  of  the 
house,  contiguous  to  the  great  staircase,  there  is,  on  the 
ground-floor  a  lobby  or  hall ;  on  the  second  floor,  the 
managers'  room ;  on  the  third  floor,  a  consulting-room 
for  the  physicians  and  surgeons,  and  a  waiting-room  for 
the  students ;  and,  on  the  attic,  a  large  theatre,  in  which 
upward  of  two  hundred  students,  at  once,  see  opera- 
tions ;  and  the  same  serves  as  a  chapel."  The  rest  of  the 
building  was  mainly  taken  uj)  by  the  wards,  the  larger 
of  which  were  eighty-one  by  twenty-six  feet  and  con- 
tained twenty-four  beds ;  the  smaller  were  fifty  by 
twenty-six  feet,  with  twelve  beds  each.  There  was  one 
window  to  two  beds.  The  service-rooms  were  placed 
at  the  ends  of  the  wards.     The  writer  goes  on  to  say : 


FIRST  BLOCK-PLAN  HOSPITAL. 


197 


H 


I  i 


s   s 


198  THE  OLD  BLOCK  FLAN. 

"  111  the  construction  of  tliis  fabric  nothing  liatli  been 
more  solicitously  attended  to  than  ventilation.  In  each 
of  the  shorter  wards,  that  is,  those  of  the  wings,  are 
opposite  windows,  a  chimney  at  one  end,  and  a  door 
opening  to  a  stair  at  the  other.  In  the  longer  wards, 
or  those  in  the  body  of  the  house,  besides  opposite  win- 
dows, is  a  door  at  each  end  leadins:  to  different  stair- 
cases,  some  of  them  having  likewise  a  chimney  at  each 
end.  Other  parts  of  the  hospital,  deemed  somewhat 
too  confined  for  the  ready  admission  of  external  air,  are 
furnished  with  artificial  ventilators."  Five  years  ago 
this  old  building  was  still  standing.  Several  other 
buildings  had  been  added,  namely  the  old  surgical 
and  the  new  surgical.  For  a  time  the  old  college- 
building  was  used  as  a  fever-hospital  ;  there  was 
also  a  lock-hospital ;  some  of  these  additions  are  on 
the  corridor  plan.  Lately,  new  pavilions  have  been 
erected. 

The  above  account  of  the  old  infirmary  would  an- 
swer very  well  for  a  descrij)tion  of  the  old  Pennsylva- 
nia Hospital  now  in  use  at  Philadelphia.  In  the  chap- 
ter on  the  "  History  of  Hospitals "  we  described  its 
origin  and  the  steps  of  its  development,  which  were 
strikingly  like  those  of  the  Edinburgh  Infirmary. 

The  old  building  of  the  Massachusetts  General  Hos- 
pital, at  Boston,  is  on  the  same  plan.  The  history  of 
the  old  New  York  Hospital  is  also  very  similar  to  that 
of  the  Edinburgh  Infirmary,  and  the  new  hosj^ital  lately 
completed  in  this  city  on  Fifteenth  Street  by  the  govern- 
ors of  the  New  York  Hosj^ital  is  on  the  old  block  plan, 
and  the  ground-plans  of  the  two  hospitals  might  easily 
be  mistaken  the  one  for  the  other ;  but  the  elevation  of 
the  New  York  building  overtops  that  of  the  old  Edin- 


NBW  YORK  HOSPITAL.  199 

• 

burgli  Infirmary  by  several  stories.'  The  two  were  con- 
structed for  tlie  same  number  of  inmates  (about  two 
hundred).  The  New  York  Hosj^ital  has  all  the  faults 
of  the  old  infirmary  plan  slightly  modified  by  some 
modern  improvements  and  a  very  uncertain  and  expen- 
sive system  of  fan-ventilation;  but,  instead  of  being 
surrounded  by  four  acres  of  land,  it  is  closely  shut  in 
by  adjoining  dwelling-houses,  and  an  old  mansion,  used 
as  a  library  and  administrative  building,  fills  up  the 
court  formed  by  the  extensions. 

Taking  either  the  New  York  Hospital  lately  opened 
or  the  old  Royal  Infirmary,  of  Edinburgh,  built  a  hun- 
dred and  forty  years  ago,  as  being  about  the  best  of  the 
hospitals  on  the  old  block  plan,  we  sum  up  oui*  objec- 
tions under  three  heads : 

1.  The  wards  are  placed  one  above  the  other. 

2.  The  administrative  ofiSces,  the  kitchen,  operating- 
theatre,  the  wards,  in  fact,  the  whole  hospital,  is  under 
one  roof,  and  the  different  parts  all  communicate  more 
or  less  directly  with  each  other. 

3.  The  service-rooms  are  either  in  or  closely  con- 
nected with  the  wards. 

In  the  chapter  on  "  Construction "  we  give  in  full 
our  reasons  for  making  the  above  objections.    • 

THE   CORRIDOR  PLAN. 

The  Grand  Hospital  of  Milan,  which  we  have  classed 
under  the  irregular  conglomerate,  is  the  oldest  hospital 
with  corridors,  being  opened  in  1456  ;  but  the  corridors 
are' on  both  sides  of  the  wards  and  attached  to  the  out- 
side of  the  buildings,  instead  of  being  only  on  one  side 

»  We  speak  of  this  hospital  and  give  the  number  of  stories  on  page  35 
of  Chapter  I. 


200  THE  CORRIDOR  PLAN. 

and  within  the  building,  as  in  the  regular  corridor  hos- 
pital. We  have  not  been  able  to  trace  satisfactorily 
the  origin  and  development  of  the  corridor  plan. 

The  small  hospitals  of  this  class  usually  consist  of 
a  central  portion  and  two  wings,  the  administration 
offices  occupying  the  centre,  and  the  wards  and  their 
service-rooms  the  wings.  The  large  hospitals,  as  in  the 
old  block  plan,  are  built  more  or  less  around  a  central 
court.  In  fact,  the  corridor  plan  is  the  same  as  the  old 
block,  with  the  addition  of  a  corridor  or  narrow  passage- 
way that  runs  parallel  with  the  long  axis  of  the  ward, 
having  doors  and  windows  opening  on  the  ward.  In 
some  cases  the  corridor  runs  through  the  centre  of  the 
building,  with  the  wards  on  either  side ;  in  these  the 
wards  are  usually  quite  small,  being  often  merely  small 
rooms  containing  not  more  than  three  or  four  beds  each. 
Fig.  7  is  a  rough  sketch  of  the  principal  floor  of  St. 
Liike^s  Hospital^  of  New  York.  This  was  the  first  and 
the  only  hospital  built  on  the  corridor  j^lan  in  this 
country,  besides  being  one  of  our  first  church  hospitals. 
It  was  founded  by  the  late  Rev.  Dr.  W.  A.  Muhlen- 
berg, of  the  Protestant  Episcopal  Church,  May,  1854. 
In  the  same  year  a  newly-formed  church  sisterhood 
opened  a  temporary  hospital  in  an  adjoining  hired 
house.  Dr.  Muhlenberg,  in  a  short  historical  sketch, 
says :  "  The  chapel  being  finished,  was  oj)ened  for  divine 
service  on  Ascension-day,  1857,  and  thenceforward  on 
Sunday  afternoons,  with  the  exception  of  four  mouths 
in  the  following  winter.  This  was  done  in  advance  of 
the  opening  of  the  hospital,  for  the  purpose  of  declar- 
ing the  Christian  faith  to  be  the  ground  and  predomi- 
nating element  of  the  institution.  For  a  year,  St.  Luke's 
appeared  before  the  j^ublic  as  a  church."     A  year  later 


ST.  LUKE'S  HOSPITAL. 


201 


2    » 


<  £ 
,  o 

<!  £ 
i> 

a-:.S 
£  =  S 


w     X 


o  S-r. 


o  u 


o  5  £ 


■^  o 


a;  — 


202  THE  CORRIDOR  FLAK 

the  wards  were  opened  and  the  patients  from  the  tem- 
porary hospital  were  transferred  to  them.  As  will  be 
seen  by  the  diagram,  the  wards  and  corridors  open 
directly  on  the  chajjel.  Only  a  few  months  before  his 
death  the  venerable  Dr.  Muhlenberg,  who  for  many 
years  acted  as  superintendent,  showed  us  over  the  hos- 
pital ;  he  pointed  with  evident  pride  to  the  chapel  and 
called  it  an  immense  reservoir  of  pure  air  for  the  wards. 
At  the  time  of  our  visit  not  a  window  in  it  was  open, 
and  we  considered  it  a  rece]3tacle  for  foul  air.  Tlie 
results  of  treatment  in  this  hospital  have  been  compara- 
tively very  good,  but  we  believe  this  is  due  to  cleanli- 
ness and  good  management,  and  to  the  favorable  loca- 
tion, rather  than  to  the  plan  of  construction. 

During  the  first  half  of  this  century  the  corridor 
plan  seems  to  have  been  the  favorite,  and  was  the 
fashion  on  the  Continent  about  1848.  With  few  ex- 
ceptions the  principal  hospitals  of  Germany,  Austria, 
Russia,  and  some  of  the  smaller  states  of  Europe,  are 
all  constructed  on  this  plan.  In  most  of  these  the 
corridor  runs  along  one  side,  but  in  some  it  runs  direct- 
ly through  the  centre  of  the  building. 

Charite  Hospital^  of  Berlin,  is  on  this  plan.  It  has 
three  stories,  and  contains  fourteen  hundred  beds. 
The  CatJiolic  Hospital^  of  the  same  city,  has  three 
hundred  and  fifty  beds  in  small  wards  opening  on 
corridors. 

The  following  hospitals  are  all  constructed  on  the 
corridor  plan : 

Bethanien  Hospital^  in  Berlin,  founded  in  1847,  has 
three  stories,  and  contains  three  hundred  beds. 

Hamhurg  General  Hospital^  enlarged  in  1848,  has 
six  or  seven  hundred  beds. 


GEEMAIT  CORRIDOR  HOSPITALS.  203 

Rotterdam  Hospital.,  built  in  1850,  contains  two  Lun- 
dred  and  sixty-five  beds. 

Bremen  Hospital.,  erected  in  1850,  has  two  floors  of 
wards  and  two  hundred  and  seventy-two  beds. 

Franhfort-on-tlie-Main  Hospital.,  dated  1833,  has  two 
hundred  beds. 

Both  Kiel  and  Munich  have  lying-in  hospitals  con- 
structed on  the  corridor  plan. 

The   ground-plan  of  the  Alexandrov  Hospital^  of 
Moscow,  in  shape  resembles  a  horseshoe,  with  four  pro- 
jecting wings.     It  is  a  corridor  hospital,  built  in  1861. 
'       Hbpital  Cochin,  of  Paris,  built  in  1780,  for  one  hun- 
dred and  nineteen  beds,  is  a  corridor  hospital. 

Mancliester  Royal  Infirmary.,  England,  erected  in 
1797,  has  a  corridor  running  directly  through  the  cen- 
tre of  the  building,  with  wards  on  either  side. 

T}iQtHospital  for  Consumptives  and  Diseases  of 
the  Chest,  at  BromjDton,  built  in  1 848,  is  a  regular  cor- 
ridor hospital.  Other  hosj^itals  of  London  are  partly 
corridor  hospitals. 

Fig.  8  gives  the  ground-plan  of  the  hospital  Rudolph- 
stiftung,  of  Vienna.  This  is  one  of  the  latest  and  most 
complete  of  the  hospitals  on  the  corridor  plan.  It  was 
opened  in  1865.  Except  on  the  east  side,  the  buildings 
are  three  stories  high.  The  corridor  runs  parallel  with 
the  wards,  and  opens  into  them  on  the  north  side. 
There  are,  in  all,  eight  hundred  beds.  In  this  hospital, 
and  in  several  others  on  the  corridor  plan,  an  attemj^t 
is  made  to  divide  the  hospital  into  pavilions  by  large 
stairways  or  by  lower  buildings  intervening,  but  prac- 
tically the  hospital  is  still  under  one  roof. 

The  only  rational  object  that  seems  to  be  aimed  at, 
in  placing  a  corridor  on  one  side  or  in  the  middle  of  a 


204 


THE  CORRIDOR  PLAN. 


building  containing  liospital  wards,  is  to  afford  a  means 
of  passing  to  and  fro  without  disturbing  the  patients  as 
much  as  would  be  done  by  passing  tlirougli  the  wards. 
Where  the  building  is  divided  up  into  a  number  of 
small  wards  or  rooms,  such  a  passage-way  is  necessary. 


Fig.  8. 


a 


•  p, 

STORE 
f 


m 


hi 


[  ii 


\\  IT' I 


li      ' 


HALL  J 


l.t_J_! 


i 


'1^  / 


Hospital  Eudolph-stiftung. 

A,  administrative  offices  on  the  north  ;  1,  wards  ;  B,  baths  ;  D,  dispensary ; 

S,  stairs. 

But  one  gathers  from  the  old  writers,  and  the  talk  of 
old  men,  that  tliey  had  an  idea  the  corridor  could  be 
used  to  supply  the  wards  witb  fresli  air  without  letting 
in  the  cold  or  draughts,  and  that  the  stairways  were 
the  great  ventilating  wells.  But  w^e  know  now  that 
the  corridors  running  parallel  witk  the  wards  not  only 


OBJECTIONS  TO   TEE  CORRIDOR  PLAN.  205 

interfere  witli  tliroiigli- ventilation  from  side  to  side  and 
intercept  sunlight,  but  tliat  they  serve  as  foul-air  chan- 
nels to  convey  the  tainted  air  from  one  ward  to  an- 
other. 

Previous  to  the  completion  of  the  Lariboisiere  and 
to  the  Crimean  "War,  and  the  books  of  Miss  Nightingale, 
little  v^as  generally  known  about  sanitary  laws,  and  the 
corridor  plan  was  coj)ied  simply  because  it  "was  about 
the  only  recognized  design  that  was  a  departure  from 
the  old  conglomerate  hospitals  of  the  past,  and  did  not 
interfere  with  the  desire  of  the  founders  to  erect  a  monu- 
ment, nor  with  the  ambition  of  the  architect  to  construct 
an  imposing  edifice  on  a  small  space  of  ground.  TVe 
consider  that  corridor  hospitals  have  all  the  ftiults  of  the 
old  block  plan,  namely :  the  whole  hospital  being  under 
one  roof,  the  wards  placed  one  above  the  other ;  the 
service-rooms  in  close  proximity  to  the  wards ;  and,  be- 
sides, corridors  that  make  ventilation  more  difficult  in- 
tercept sunlight,  and  add  to  the  cost  of  construction. 

THE  PAVILION  SYSTE.AL 

In  Chaj^ter  I.  we  gave  some  account  of  the  origin 
and  develo2">ment  of  the  pavilion  plan.  Miss  Nightin- 
gale, in  her  "Notes  on  Hospitals,"  says:  "The  first 
princij^le  of  hospital  constiniction  is  to  divide  the  sick 
among  separate  j^avilions.  By  a  hospital  pavilion  is 
meant  a  detached  block  of  buildings,  capable  of  con- 
taining the  largest  number  of  beds  that  can  be  placed 
safely  in  it,  together  with  suitable  nurses'  rooms,  ward 
sculleries,  lavatories,  baths,  water-closets,  all  complete, 
proportioned  to  the  number  of  sick,  and  quite  uncon- 
nected Avith  any  other  pavilion  of  which  the  hospital 
may  consist,  or  with  the  general  administration  offices, 


206  THE  PAVILIOX  PLAN. 

excejDt  by  liglit,  airy  passages  or  corridors.  A  j^avilion 
is  indeed  a  sej^arate  detached  hospital,  wliicli  has,  or 
ouo-ht  to  have,  as  little  connection  in  its  ventilation  with 
any  other  ^ari  of  the  hospital  as  if  it  were  really  a 
separate  establishment  miles  away.  The  essential  feat- 
ure of  the  pavilion  construction  is  that  of  breaking  up 
hospitals  of  any  size  into  a  number  of  separate  detached 
parts,  having  a  common  administration,  but  nothing 
else  in  common.  ,  And  the  ol^ject  sought  is,  that  the 
atmosphere  of  no  one  ^^avilion  or  ward  should  dif- 
fuse itself  to  any  other  pavilion  or  ward,  but  should 
escape  into  the  open  air  as  speedily  as  possible,  while 
its  place  is  supplied  by  the  purest  air  from  the  out- 
side." 

The  first  hosj^ital  with  separate  pavilions,  so  far  as 
we  can  learn,  was  erected  in  1756-64  at  Stonehouse, 
near  Plymouth,  England.  The  famous  report  of  the 
committee  of  the  French  Academy  of  Sciences  was 
made  in  1786. 

St.  Andre  General  Hospital^  of  Bordeaux,  founded 
in  1390  and  rebuilt  1829,  was  the  first  complete  hospi- 
tal constructed  according  to  the  principles  laid  down 
by  the  rej)ort  of  the  Academy's  committee.  It  has  six 
hundred  and  fifty-four  beds  in  twenty-four  wards  ;  the 
pavilions  are  arranged  on  either  side  of  an  open  court, 
around  which  runs  an  open  gallery  or  corridor  connect- 
ing the  pavilions  on  the  ground-floor. 

Hopital  St.  J'ean,  at  Brussels,  was  completed  in  1843. 
It  consists  of  ten  pavilions,  only  thirty-five  feet  apart, 
and  connected  by  a  two-story  corridor. 

Hospital  Za  Princesse^  of  Madrid,  is  a  modern 
building  on  the  pavilion  j^lan.  There  are  eight  ]3avil- 
ions,  four  on  each  side  of  a  large  inclosed  sj)ace,  and 


LARIBOISIERE  HOSPITAL. 


207 


connected  by  a  corridor     It  contains  three  hundred 
and  fifty  beds. 

Fig.  9  is  the  ground-plan  of  Larihoisiere,  commenced 


Fig.  9. 


G 


sL. 


c 


1 


IL 


H    i-&-  Li 


i 


isij?-fijusn    m 


1= 


m 

IE 


d 


Id 


n. 


zz^iy 


rrl^Tl  -. 


■M 


m 


HiiL 


h 


i-p 


IS 


3 


3 


nzfi 


ia 


HopiTAL  Lariboisiere. 


in  1846,  on  plans  furnished  by  Gauthier,  and  finished  in 
1854. 

This  hospital  consists  of  a  series  of  pavilions,  ar- 
ranged on  two  parallel  lines,  separated  by  an  inclosed 
space  laid  out  as  a   garden.     There  are  six  of  these 


208  THE  PA  VILION  PLAK 

cletaclied  buildings  for  patients,  containing  in  all  six 
hundred  and  six  beds ;  in  front  are  buildings  for  tlie 
offices,  kitchen,  and  pharmacy,  parallel  with  those  for 
the  sisters  and  attendants,  the  laundry,  chapel,  operat- 
ing-room, baths,  etc.,  at  the  end  farthest  from  the  en- 
trance. The  pavilions  contain  three  floors  of  wards ; 
one  large  ward  for  thirty-two  beds,  and  one  small 
adjoining  ward  for  two  beds  on  each  floor.  Each  ward 
has  a  sister's  room  and  scullery ;  at  the  ends  are  closets, 
baths,  etc. ;  and  a  spacious  staircase  gives  access  to  the 
wards.  All  the  23avilions  are  connected  by  a  glazed 
corridor,  one  floor  in  height,  over  which  is  an  open  ter- 
race, used  by  convalescents,  and  also  as  a  means  of 
access  between  the  first  floors  when  the  weather  per- 
mits. 

Any  one  visiting  this  splendid  hospital  with  its  pol- 
ished floors,  its  walls  of  Parian  cement,  its  costly  ma- 
chinery for  artificial  ventilation,  etc.,  etc.,  would  be 
inclined  to  think  that  it  is  perfect — that  the  patients 
must  do  Avell.  But  time  has  shown  a  different  result. 
Its  records  give  a  mortality  but  little  less  than  that  of 
the  old  hospitals.  It  may  be  well  asked.  Why  is  it  not 
a  success  ? 

1.  Forced  or  artificial  ventilation  cannot  with  safety 
be  made  to  take  the  place  of  natural  or  normal  circula- 
tion of  unadulterated,  fresh  air,  purified  by  the  direct 
rays  of  the  sun. 

2.  The  area  on  which  the  buildings  stand  is  too 
small  for  a  hospital  of  six  hundred  and  six  beds. 

3.  The  pavilions  are  three  stories  high  and  only 
sixty  feet  apart,  which  is  not  sufficient  space  to  allow  a 
free  circulation  of  air. 

4.  The  wards  all  communicate  with  a  stairway  at 


NEW  ST.   THOMAS'S  HO  SPIT  A  L.  209 

one  end,  so  that  impure  air  readily  passes  from  one  to 
the  other;  and,  as  the  pavilions  are  connected  by 
large,  spacious  corridors,  without  doubt  air  is  often 
interchanged  from  one  pavilion  to  another. 

5.  The  closets,  baths,  and  sinks,  are  placed  at  the 
ends  of  the  wards,  so  that  a  current  of  air  passing  from 
end  to  end  in  the  ward  is  liable  to  be  made  impure  at 
all  times. 

6.  The  pavilions  are  arranged  around  a  court. 
New  St.  Thomases  Hospital^  in  London,  with  the 

exception  that  the  pavilions  have  foui-  floors  of  wards 
instead  of  two,  is  built  after  the  plans  given  in  Miss 
Nightingale's  book,  "Notes  on  Hosj^itals."  On  the 
Thames  embankment  the  eight  jDavilions  of  St.  Thom- 
as's Hospital  rear  their  stately  fagades  for  a  quarter  of 
a  mile  opposite  the  Houses  of  Parliament  and  West- 
minster Abbey.  These  pavilions  are  built  of  red  brick, 
faced  with  sandstone,  and  covered  w^ith  slate.  They 
are  situated  about  one  hundred  feet  apart,  the  first  and 
second  stories  being  connected  in  front  by  corridors. 
The  disiDensaries,  drug-shop,  etc.,  form  a  part  of  the  cor- 
ridors. The  pavilions  at  either  end  are  appropriated, 
one  to  the  executive  offices,  and  the  other  to  the  medi- 
cal college.  The  hosj)ital  contains  twenty  wards,  hav- 
ing from  twenty  to  twenty-eight  beds  each,  with  a  small 
ward  of  two  beds  attached  to  each,  the  sixth  pavilion 
being  used  for  infectious  cases,  and  containiug  seven 
wards  of  eight  beds  each.  It  is  without  doubt  the 
most  magnificent  hospital,  and  perhaps  the  finest  struct- 
ure used  for  charitable  purposes,  in  the  world.  The 
administrative  and  executive  facilities  could  not  be 
more  complete,  even  to  the  smallest  detail;  neither 
space  nor  cost  has  been  spared. 
14 


210 


TEE  CORRIDOR  PLAN. 


Altliougli  free  from  some,  yet  it  has  most  of  tlie 
same  serious  faults  which  have  been  enumerated  while 
speaking  of  the  Lariboisiere,  namely :  The  pavilions  have 
too  many  stories ;  the  corridors  are  so  constructed  that 
there  must  be  more  or  less  intercommunication  of  the 
atmosphere  of  one  pavilion  with  another.  The  nurses' 
room,  small  ward,  etc,  block  up  one  end,  while  the  clos- 
ets and  baths  fill  up  to  a  great  extent  the  other  end  of 
the  wards.     It  is  a  great  imj^rovement  on  the  old  plans ; 


Herbert  Hospital. 


but  so  far  the  practical  results  have  not  been  altogether 
satisfactory. 

Fig.  10  represents  the  ground-j^lan  of  Herbert  Hos- 
pital at  Woolwich,  built  in  1863.  At  the  time  of  its 
erection  it  was  considered  by  Miss  Nightingale  as  fully 
carrying  out  the  true  princij^les  of  hospital-construction. 
It  consists  of  four  double  and  three  single  two-story 
pavilions  on  a  raised  basement,  connected  by  a  corridor 
through  the  centre.     The  corridor  is  of  one  story,  with  a 


E2TGLISH  CORRIDOR  HOSPITALS.  211 

basement.  There  are  six  liundred  and  fifty  beds.  The 
wards  are  twenty-six  and  a  half  feet  wide,  fourteen  feet 
long,  and  each  bed  has  ninety-five  superficial  feet  and 
fourteen  hundred  cubic  feet  of  sj^ace.  To  every  two 
beds  there  is  one  window. 

The  late  writers  on  hospital-construction,  as  Galton, 
also  put  forward  the  Herbert  Hospital  as  a  model.  We 
would  make  the  same  objections  that  we  made  to  New 
St.  Thomas's,  for,  with  the  exception  of  being  tAvo  sto- 
ries only  to  the  pavilions,  it  is  almost  exactly  the  same. 

Blachbiirn  Infijinary^  England,  commenced  in  1859, 
M'as  one  of  the  first  pavilion  hospitals  built  in  England. 
It  occupies  eight  acres  of  land,  not  far  from  Manchester, 
and  is  composed  of  six  detached  two-story  pavilions 
runnino;  risjht  and  left  from  a  connectinsr  corridor. 

Glasgow  Surgical  Hospital  is  a  pavilion  hospital 
built  in  1860.  It  has  one  hundred  and  ninety-eight 
beds — eight  wards  of  nineteen  beds  each — two  wards 
to  a  floor,  with  a  staircase  between  them.  The  wards 
are  closed  at  both  ends. 

The  New  Infirmary  built  at  Leeds,  England,  is  a 
large  pavilion  hospital.  It  consists  of  five  buildings, 
each  two  stories  high,  connected  by  a  corridor. 

The  CJiorlton  Union  Worhliouse  Hospital  i^  also  a 
new  i^avilion  hospital.  In  fact,  throughout  the  United 
Kingdom  of  Great  Britain  the  teachings  of  Miss  Night- 
ingale are  generally  acce]:)ted  and  carried  out  wherever 
new  hospitals  are  built. 

Fig.  11  gives  the  plan  of  the  Hospital  of  the  Prot- 
estant Episcopal  Churchy  of  Philadelphia.  This  was  the 
first  hospital  constructed  in  America  in  which  the  sug- 
gestions of  the  French  Academy's  committee  were  car- 
ried out.     Mr.  Samuel  Sloan  ^vas  the  architect.     The 


212 


THE  FA  YILION  FLAK 


corner-stone  was  laid  May,  1860.  The  hospital  consists 
of  a  central  administrative  building,  containing  a  very 
large  chapel,  operating-theatre,  and  offices.  On  either 
side  parallel  with  the  administrative  building  are  the 
detached  pavilions  containing  the  wards.  In  each  j)a- 
vilion  there  are  two  floors  of  wards  above  the  base- 


FlG.    11. 


Hospital  of  the  Protestant  Episcopal  Church,  of  Philadelphia. 

ment,  besides  an  attic  in  w^hich  are  rooms  for  special 
cases.  These  pavilions  are  connected  with  the  admin- 
istrative building  by  a  two-story  corridor  running  at 
right  angles  with  them.  The  wards  are  one  hundred 
and  twenty  feet  long,  thirty  feet  ten  inches  wide,  by 
sixteen  feet  in  height,  and  contain  thirty  beds  each. 


PAVILION  HOSPITALS   OF  MEW   YORK.  213 

In  1863  tlie  Boston  Free  City  Hospital  was  partly 
built.  The  original  plan  consisted  of  a  grand  central 
administrative  building,  connected  with  six  widely- 
detached,  three-story  pavilions  by  curved,  one-stoiy 
corridors.  Only  two  of  the  j)avilions  on  the  old  plan 
were  erected.  Within  the  past  three  years  several  one- 
story  pavilions  have  been  built  on  the  grounds. 

In  1867  one  of  the  pavilions  of  the  New  Yorh  State 
Womaii's  Hospital  was  opened,  and  the  second  pavil- 
ion was  finished  a  few  months  since.  The  buildings 
are  handsome  structures,  with  four  floors  of  wards, 
and  together  can  accommodate  one  hundred  and 
thirty-five  patients.  The  two  pavilions  are  almost 
exactly  alike.  In  the  basement  are  the  kitchen  and 
store-rooms.  The  first  floor  is  divided  by  a  hall  and 
partitioned  into  private  rooms.  The  second  and  third 
floors  are  alike,  and  have  fourteen  beds  each.  The 
fourth  floor  has  twenty-four  beds.  Each  ward  has  its 
water-closets  and  bath-room  and  nurses'  room,  or  small 
ward,  at  one  end,  where  there  are  a  service-staircase  and 
dumb-waiter  from  the  basement  to  the  top  ward ;  and 
at  the  other  end  are  a  wide  stairway  and  an  elevator  for 
carrying  up  patients — one  of  the  first  ever  introduced 
into  a  hospital  for  that  purpose.  There  are  also  in  this 
end  the  reception-roorn,  office  for  the  house-surgeon,  and 
an  operating-room.  The  j^avilions  are  situated  with 
their  long  axes  east  and  west;  consequently  the  sun 
shines  only  on  one  side. 

The  cases  treated  in  this  hospital  are  confined  to 
diseases  j)eculiar  to  ^romen;  no  lying-in  women  are 
received.  The  author  resided  in  the  older  of  these 
pavilions  as  house-surgeon  for  eighteen  months,  and 
knows  from  personal  experience  that  the  whole  build- 


214  THE  PAVILION  PLAN. 

ing  liad  a  common  atmosphere ;  tliat  tlie  patients  on  tlie 
fourtli  floor  could  not  help  knowing  what  they  were  to 
have  for  dinner  long  before  it  reached  them ;  and  that 
patients  in  all  the  wards  suffered  from  malarial  poison 
arising  from  defective  drainage  in  the  cellar.  After 
the  buildings  had  been  in  use  a  few  years,  it  began  to 
be  risky  to  operate  upon  certain  cases,  and  within  the 
past  few  months  it  has  been  decided  to  erect  huts  or 
cottages  for  the  cases  of  ovariotomy,  as  lately  nearly  all 
such  cases  operated  on  have  died. 

Since  the  erection  of  the  first  pavilion  of  the  Wom- 
an's Hospital  several  new  hospitals  on  the  pavilion  plan 
have  been  built  in  ISTew  York  City,  or  at  least  partly 
built,  one  or  more  pavilions  of  each  being  completed, 
and  are  now  in  use.  The  largest  of  these  is  the  JRoose- 
velt  Hospital ;  that  is  designed  for  three  hundred  beds, 
and  now  has  room  for  one  hundred  and  eighty  ;  one  of 
the  pavilions  of  this  hospital  is  only  one  story  high. 
We  will  speak  of  it  again. 

Mount  Sinai  Hospital  for  IGO  beds,  is  completed. 

The  German  Hospital  has  one  large  pavilion  com- 
pleted; and  \hQ  Presbyterian  Hospital  has  an  elegant 
administrative  building,  kitchen,  laundry,  steam-engine, 
etc.,  but  only  one  central  pavilion  finished  for  seventy 
beds. 

To  criticise  one  of  these  is  to  criticise  all,  for  they 
are  on  very  much  the  same  plan,  all  three  or  four  stories 
high,  with  service-rooms,  etc.,  at  the  ends,  and  all,  ex- 
cept the  Roosevelt,  have  the  j^avilions  so  placed  as  to 
get  sunlight  only  on  one  side. 

There  is  a  hospital  in  Providence,  R.  I.,  the  MJiode 
Island  Hospital^  on  the  pavilion  plan,  very  much  the 
same  as  the  new  hospitals  of  this  city. 


OBJECTIONS  TO   THE  PAVILION  PLAN.  215 

San  Francisco,  California,  lias  a  large,  two-story 
pavilion  hospital  situated  in  spacious  grounds.  Chicac-o 
is  to  liave  a  large  pavilion  hospital ;  one  of  the  pavil- 
ions, of  several  stories,  has  been  built.  There  are  sev- 
eral other  smaller  ones  in  the  United  States  on  the 
same  plan. 

The  regular  pavilion  plan  is  but  a  modification  of 
the  old  block  plan,  and  we  have  exactly  the  same  objec- 
tions to  it.  We  cannot  say  that  all  the  hospital  is  un- 
der one  roof,  but,  where  there  are  more  than  thirty 
j^atients  to  the  pavilion,  we  do  say  there  are  too  many 
patients  under  one  roof.  The  wards  are  placed  one 
above  the  other,  and  the  service-rooms  are  in  close 
proximity  to  the  wards. 

THE  ONE-STORY  PAVILION  PLAN. 

The  principles  of  the  one-story  pavilion  or  barrack 
plan  are  precisely  those  laid  down  by  the  committee 
of  the  French  Academy  and  taught  by  Miss  Nightin- 
gale, but  the  pavilions  are  all  limited  to  one  story  in 
height  and  to  one  ward  to  each  pavilion.  In  Chapter 
I.  we  have  described  their  origin  and  development. 

Fig.  12  gives  the  plan  of  the  one-story  pavilion  of 
the  Presbyterian  Hospital,  of  Philadelphia.  This  build- 
ing  was  completed  in  1875,  and  illustrates  very  well 
about  the  best  of  the  one-story  pavilions  that  have  been 
erected. 

As  will  be  seen  by  comparing  this  diagram  with 
the  plate  giving  our  drawing  for  a  surgical  pavilion, 
the  plans  are  somewhat  alike ;  but  in  this  the  service- 
rooms  are  in  the  same  building  as  the  patients,  the  win- 
dows are  too  few,  the  beds  too  close  together,  and  the 


216 


THE  ONE-STORY  PAVILION  PLAN. 


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LliiJ_.S 


AMERICAN  ONE-STORY  PAVILION  HOSPITALS.     217 

sitting-room  at  tlie  end  of  tlie  ward  interferes  witli  tlie 
ventilation. 

In  this  country  a  number  of  one-story  pavilions,  in 
connection  with  large  civil  hospitals,  have  been  erected 
since  the  civil  war.  On  Blackwell's  Island  the  New 
York  City  authorities  had  a  number  of  simple  wooden, 
one-story  pavilions  built  on  the  jjlan  of  those  used  for 
the  temporary  hospitals  during  the  war.  The  first  were 
fever  wards,  but  lately  all  the  new  buildings  for  the  sick 
are  on  the  one-story  plan,  and  at  present  two  one-story 
pavilions,  to  be  used  as  a  lying-in  hospital,  are  being 
constructed  in  which  the  wards  will  be  separated  from 
the  service-building  by  a  space  of  ten  feet  and  connected 
by  a  short  straight  corridor.  One  of  the  surgical  wards 
of  the  Roosevelt  Hospital  is  in  a  handsome  one-story 
pavilion ;  but  the  building  has  a  cellar  beneath  it,  and 
at  the  end  adjoining  the  corridor  are  all  the  service- 
rooms  except  the  water-closets  and  baths,  which  are  in 
a  small  structure  projecting  from  the  side  of  the  ward 
near  the  centre — a  very  ol)jectionable  place. 

In  Boston  there  are  several  one-story  j^avilion  wards ; 
those  on  the  grounds  of  the  Boston  Free  City  Hospital 
are  of  the  usual  rectangular  shape,  with  service-rooms 
directly  connected  with  Avards.  One  of  the  pavilions 
of  the  3£assacliusetts  General  Hospital  has  a  square 
ward  similar  to  that  given  by  one  of  the  essayists  in 
the  Johns  Hopkins  Hospital  book,  a  review  of  Avhich 
will  be  found  in  our  Appendix, 

The  plans  for  the  United  States  Marine  Hospital  at 
San  Francisco,  California,  are  one-story  pavilions,  like 
those  used  for  army  hospitals  during  our  civil  war. 

In  Great  Britain  the  Glasgow  Fever  Hospital  was 
one  of  the  first  one-story  pavilion  hospitals  erected. 


218  THE  ONE-STORY  PAVILION  PLAN. 

It  consists  of  four  parallel  double  pavilious  oue  story 
high.  Three  are  built  of  wood  on  brick  pillars.  The 
fourth  is  of  brick  with  hollow  walls.  There  are  ridge- 
sashes  and  opposite  windows.  There  are  eleven  beds 
to  the  ward,  and  a  small  ward  adjoining. 

Fig.  13  gives  the  plan  of  the  Rotlierham  Hospital^ 
built  in  1872.  This  is  one  of  the  best  and  most  com- 
plete small  hospitals  in  England.  The  buildings  are 
of  stone.  The  pavilions  are  one  stoiy  high,  and  raised 
some  distance  from  the  ground,  and  sixty  feet  apart. 
The  water-closets  and  baths  are  in  the  small  projections 
at  the  free  ends  of  the  wards.  The  small  buildings  at 
the  ends  of*  the  corridors  are  wards  for  special  cases, 
and  the  two  between  the  pavilions  are  wards  for  con- 
valescents. The  pavilions  contain  respectively  twelve, 
ten,  and  eight  beds. 

During  the  late  Franco-German  War  both  parties, 
especially  the  Germau,  adopted  the  American  system 
of  erecting  large  temporary  hospitals,  composed  of  a 
great  number  of  one-story  pavilions,  built  of  wood,  and 
in  some  cases  connected  with  the  administrative  build- 
ing and  with  each  other  by  a  corridor. 

Dr.  Esse  had  a  one-story  wooden  pavilion  erected  in 
connection  with  Charity  Hospital,  of  Berlin,  in  1867, 
and  since  then  several  civil  hospitals  on  the  American 
one-story  or  barrack  plan  have  been  constructed,  two 
of  which  we  speak  of  in  Chapter  I. — one  at  Leipsic,  the 
other  at  Kiel.  The  new  City  Hospital  at  Friedrichs- 
hain,  Berlin,  built  in  1870,  is  a  pavilion-hospital.  Some 
of  the  wards  are  in  one-story  and  others  in  two-story 
pavilions.  The  pavilions  are  widely  detached,  and  have 
no  connecting  corridors — only  gravel-walks  between. 

To  the  best  of  the  one-story  pavilions  we  can  make 


ROTE  ERE  AM  HOSPITAL. 


219 


220  THE  ONE-STORY  PAVILION  PLAN. 

but  one  of  tlie  three  objections  wliicli  we  made  to  tlie 
old  block  plan,  for  the  hospital  is  not  all  under  one 
roof,  nor  are  the  wards  placed  one  above  the  other ; 
but  the  service-rooms,  namely  the  water-closets,  the 
bath-room,  the  nurses'  room,  the  scullery,  and  in  some 
cases  a  small  ward,  are  all  directl}^  connected  with  the 
ward  under  the  same  roof,  and  alwaj^s  blocking  up  one 
and  in  many  cases  both  ends  9f  the  ward. 

How  to  correct  the  above  faults,  and  to  erect  a  hos- 
pital on  an  improved  one-story  pavilion  plan,  we  en- 
deavored to  show  in  the  chapter  on  "  Hospital-Con- 
struction." 


appe:n"  d  IX. 


A  Review  of  "  Five  Essays  relating  to  the  Construction,  Organization,  and  Manage- 
ment of  Hospitals,  contributed  hy  their  Authors,  for  the  Use  of  the  Johns  Hop- 
kins Hospital  of  Baltimore."  Large  8vo,  pp.  xxi.-353.  Numerous  Plates. 
New  York :  William  Wood  &  Co.,  18Y5.  (Renew  written  for  the  Standing 
Committee  on  Hospitals,  State  Charities  Aid  Association,  at  the  request  of  Mr. 
King.) 

The  object  of  this  book  is  fully  and  clearly  stated  in  the  letter 
of  Mr.  King,  the  President  of  the  Board  of  Trustees,  and  may  be 
given  in  a  few  words.  The  late  Johns  Hopkins,  a  wealthy  citizen 
of  Baltimore,  bequeathed  several  million  dollars  (now  estimated  to 
be  86,000,000)  to  trustees,  with  which  to  found  a  university,  a  col- 
ored orphan  asylum,  and  a  hospital,  and  he  added  fourteen  acres 
of  land  in  the  city  of  Baltimore,  on  which  the  hospital  is  to  be 
built. 

In  a  letter  to  the  trustees  Mr.  Hopkins  very  definitely  describes 
his  wishes  concerning  the  trust. 

The  hospital  is  to  be  a  general  medical  and  surgical  hospital, 
and  to  contain  four  hundred  beds '  when  finished.  The  sick  poor, 
without  regard  to  sex,  age,  or  color,  are  to  be  received  into  it  free 
of  cost,  and  a  number  of  beds  are  to  be  provided  for  strangers  and 
others  able  and  willing  to  pay.  The  hospital  is  to  have  a  training- 
school  for  nurses  established  in  connection  with  it,  and  is  to  be 
used  to  afford  clinical  teaching  for  the  medical  school  of  the  uni- 
versity. 

In  his  letter  Mr.  Hopkins  enjoined  the  trustees  "  to  obtain  the 

*  Working  basis  reduced  now  to  three  hundred  beds. 


222  APPENDIX. 

advice  and  assistance  of  those  at  home  and  abroad  who  have 
achieved  the  greatest  success  in  the  construction  and  management 
of  hospitals."    In  accordance  with  this  request  the  trustees  selected 

John  S.  Billings,  Brevet  Lieutenant-Colonel  and  Assistant  Sur- 
geon, U.  S.  A.  ; 
NoRTOisr  FoLSOM,  M.  D.,  of  Boston  ; 
Joseph  Jones,  M.  D.,  of  New  Orleans  ; 
Caspak  Morris,  M.  D.,  of  Philadelphia ; 
Stephen  Smith,  M.  D.,  of  New  York — 

each  to  prepare  an  essay  upon  the  construction  and  organization 
of  the  proposed  Johns  Hopkins  Hospital. 

Before  taking  up  the  discussion  of  the  essays,  we  must  speak 
of  the  "  Letters  of  Instruction  "  that  preface  them,  one  from  Mr. 
Hopkins  to  the  trustees,  the  other  from  Mr.  King,  the  President  of 
the  Board  of  Trustees,  to  the  authors  of  the  essays. 

Dr.  Folsom  in  his  paper,  speaking  of  Mr.  Hopkins's  letter  ad- 
dressed to  the  trustees,  very  aptly  says :  "  It  evidences  not  only 
benevolence,  but  wisdom.  It  shows  not  only  solicitude  for  the 
welfare  of  the  poor  and  suffering,  but  a  keen  appreciation  of  their 
necessities,  and  discriminating  skill  in  planning  their  relief."  Mr. 
Hopkins  has  not  alone  shown  his  wisdom  and  practical  judgment 
in  defining  his  wishes,  but  has  displayed  equal  foresight  in  the 
selection  of  the  men  who  are  to  carry  out  his  intentions.  We 
speak  of  this,  because,  in  a  great  majority  of  instances,  trustees  of 
hospitals  are  chosen  mainly  on  account  of  high  social  position,  or 
for  generous  contributions  to  the  finances,  and  seldom  have  much 
actual  practical  knowledge  about  such  institutions.  Mr.  King's 
letter  shows  plainly  that,  if  he  has  not  had  actual  experience  in 
hospitals,  he  has  at  least  made  himself  familiar  with  their  organi- 
zation, construction,  and  management,  and  that  he  has  broad  and 
comprehensive  views  upon  the  subject. 

The  steps  so  far  taken  by  the  trustees  of  the  Johns  Hopkins 
fund  toward  the  building  of  the  hospital  are  in  striking  contrast 
with  those  pursued  by  most  boards  of  managers  of  hospitals,  and 
we  believe  that  the  contrast  will  be  still  more  marked  in  the  future 
when  a  comparison  can  be  made  between  the  practical  workings  of 
the  various  institutions. 

The  only  fault  we  have  to  find  with  Mr,  King's  letter  of  instruc- 
tion is,  the  short  time  allowed  for  preparing  the  essays  ;  it  should 


REVIEW  OF  DR.   BILLINGS'S  ESSAY.  223 

have  been  six  instead  of  two  months.  To  this  unavoidable  haste 
we  are  inclined  to  attribute  the  marked  want  of  completeness  that 
is  noticeable,  with  one  exception,  in  all  of  the  five  essays. 


DR.   BILLINGS'S  PLAN. 

The  first  essay  is  by  J.  S.  Billings,  M.  D,,  who  begins  his  paper 
with  some  good  suggestions  about  the  medical  school. 

The  remarks  on  organization  and  management  are  very  general, 
and  some  important  points  are  treated  of  in  a  very  few  lines.  For 
instance,  a  mere  reference  is  made  to  the  training-school  for 
nurses,  for  which  it  is  observed  a  separate  building  should  be 
prepared ;  but  no  plan  of  organization  is  given,  nor  is  the  subject 
again  referred  to. 

"  On  the  Causes  of  Hospitalism  ;  or,  the  Hurtful  Influence  of 
Hospitals,"  an  interesting  chapter  is  given  :  not  that  there  is 
much  that  is  new  in  it,  but  that  it  is  a  clear  statement  of  the  nature 
and  action  of  hospital  poisons,  so  far  as  these  are  understood,  and 
is  not  to  be  found  in  other  books  on  hospital-construction. 

What  Dr.  Billings  has  to  say  about  temporary  versus  perma- 
nent hospitals  is  exceedingly  interesting.  He  begins  by  giving  his 
reasons  for  having  advocated  the  proposition  a  few  years  since, 
that  "no  hospital  should  be  constructed  with  a  view  to  its  being 
used  as  such  for  more  than  fifteen  years."  After  stating  under 
what  circumstances  he  did  so,  he  says  :  "  But  the  statement  that 
this  temporary  character  should  be  adopted  for  all  hospitals  and 
especially  all  parts  of  hospitals,  was,  I  am  now  satisfied,  too  sweep- 
ing." He  then  makes  some  remarks  both  for  and  against  the  bar- 
rack-system, and  concludes  as  follows  :  "  I  am  of  the  opinion  that 
all  the  good  qualities  of  a  barrack  or  tent  hospital  can  be  combined 
with  those  of  a  permanent  structure  in  such  a  manner  as  to  secure 
both  the  healthfulness  of  the  one  and  to  a  considerable  extent  the 
convenient  and  economical  administration  of  the  other,  and  such  a 
plan  I  will  attempt  to  indicate."  We,  too,  believe  that  such  a 
building  can  be  adapted  to  the  successful  treatment  of  the  great 
majority,  but  not  of  all  classes,  of  cases. 

Dr.  Billings  next  takes  up  the  question  of  heating  and  ventila- 
tion, his  plan  for  which,  he  candidly  admits,  will  be  an  experiment. 
In  his  discussion  of  the  subject  and  in  his  assertion  that  two-story 


224  APPENDIX. 

pavilions  may  be  made  to  furnish  results  equal  to  those  of  one 
story,  especially  in  a  case  like  this  where  land  is  abundant,  he 
appears  to  us  to  give  too  much  weight  to  theoretical  views,  and 
shows  a  tendency  to  overlook  the  results  of  experience,  and  to  fol- 
low in  the  same  steps  that  have  led  to  the  erection  of  all  our  mag- 
nificent civil  hospitals,  which  he  nevertheless  admits  to  have  been 
failures. 

It  is  indeed  difficult  to  understand  why  methods  of  ventilation, 
theoretically  so  complete  and  perfect,  have  failed  to  give  good 
results  when  jout  in  practice.  And  yet  it  is  a  fact  that,  so  far, 
simple  one-story  buildings,  with  but  little  or  no  mechanical  con- 
trivances to  perfect  the  ventilation,  have  given  the  best  and  the 
only  satisfactory  results  in  the  treatment  of  a  large  and  important 
class  of  patients  ;  while,  on  the  contrary,  those  hospitals  con- 
structed at  a  great  cost  Avith  (from  a  theoretical  standpoint)  all 
the  necessary  contrivances  for  making  the  ventilation  a  near 
approach  to  perfection,  as,  for  instance,  Lariboisiere,  have  failed 
to  give  as  good  results  as  similar  buildings  without  the  mechanical 
ventilating  apparatus. 

The  general  plan  for  the  wards  and  service-rooms,  in  Dr.  Bil- 
lings's essay,  does  not  diflfer  essentially  from  that  recommended  by 
Miss  Nightingale. 

We  think  the  plan  of  having  the  wards  raised  on  basements  so 
that  the  top  of  the  corridor  may  serve  as  a  walk  on  a  level  with 
the  floor  of  the  ward  a  good  one,  and  we  approve  of  the  wall  and 
the  cubic  space  allowed  each  bed,  and  the  number  of  beds  to  each 
ward  ;  but  we  think  the  service-rooms  and  the  small  wards  take  up 
too  much  space,  and  Avill  make  the  plan  expensive,  besides  block- 
ing the  end  of  the  ward. 

We  would  separate,  in  fact  isolate,  the  service-rooms  from  the 
ward,  placing  them  near  the  end  of  the  ward,  a  little  to  one  side 
of  and  connected  with  it  by  means  of  a  short  corridor.  The  object 
thus  aimed  at  is — 1.  To  avoid  the  danger  which  is  to  be  appre- 
hended from  the  proximity  of  the  numerous  partitions,  doors,  etc., 
as  affording  places  for  harboring  infection  ;  and  from  the  emana- 
tions from  water-closets,  drains,  sinks,  and  dining-rooms  ;  3.  To 
diminish  the  risk  of  the  foul  air  of  one  ward  reaching  other  wards 
by  means  of  the  corridors  ;  3.  To  leave  the  ends  of  the  ward  free, 
so  that  a  current  of  air  can  pass  through  the  ward  as  readily  from 
end  to  end  as  from  side  to  side  ;  4.  That  if  need  be,  on  account 


REVIEW  OF  DR.  BILLINGS'S  ESSAY.  225 

of  the  ward  becoming  infected,  it  can  be  destroyed,  leaving  intact 
the  basement  and  the  service-rooms.' 

Instead  of  the  plan  given  for  the  private  or  pay  patients'  pavil- 
ions, we  would  have  them  similar  to  the  pavilions  for  the  other 
patients,  with  this  difference  :  they  should  be  forty  feet  wide  in 
place  of  thirty,  so  as  to  allow  for  a  corridor  in  the  centre  with 
rooms  on  both  sides,  say  twelve  by  fifteen  feet  each,  heated  by  an 
open  grate.  The  ward  containing  the  rooms  should  be  as  com- 
pletely separated  from  the  service-rooms  as  was  recommended  for 
the  others. 

After  reading  Dr.  Billings's  remarks  on  hospitalism,  we  are  sur- 
prised to  find  him  recommending  that  the  amphitheatre  for  opera- 
tions should  be  crowded  into  the  same  building  with  the  post-mor- 
tem and  pathological  rooms.  If  what  he  says  about  these  "  disease- 
germs,"  these  little  infectious  floating  particles,  is  true,  then  every 
patient  operated  upon  and  every  wound  exposed  in  the  operating- 
amphitheatre  would  be  liable  to  be  poisoned — infected  with  a  fatal 
disease — before  they  enter  the  wards. 

If  the  j^ost-mortem  and  jDathological  rooms  are  placed  on  the 
grounds  at  all,  they  should  be  in  one  corner  of  the  lot,  as  complete- 
ly isolated  as  possible.  They  should,  under  any  circumstances, 
have  all  attendants,  both  medical  and  others,  entirely  distinct  from 
those  of  the  hospital,  and  the  buildings  might  very  well  be  sepa- 
rated from  the  rest  of  the  hospital  by  a  high  stone-wall.  The 
operating-theatre  should  be  kept  as  well  ventilated  and  as  pure 
and  fresh  as  the  wards  themselves. 

Under  the  head  of  "General  Plan  of  Hospital"  Dr.  Billings 
gives  some  good  suggestions  on  the  classification  of  patients  ;  and, 
although  we  think  to  carry  out  this  to  the  extent  he  recommends 
wOl  be  a  difficult  matter,  still,  it  should  be  done  as  far  as  is  prac- 
ticable. 

Judging  from  what  we  know  of  pavilions  of  one,  two,  and  three 
stories,  erected  in  this  city,  Boston,  and  Philadelphia,  it  strikes  us 
that  Dr.  Billings's  estimate  of  the  cost  of  his  buildings  is  too  Ioav 
by  at  least  one-third  of  the  amount  given. 

'  A  full  description,  with  drawings  and  plan  for  carrying  out  this  idea,  was 
given  in  a  paper  read  before  the  State  Charities  Aid  Association  in  New  York, 
December,  18Y3,  and  a  brief  reference  to  it  published  in  the  report  of 'the  special 
committee  appointed  to  take  active  measures  for  the  erection  of  a  new  Bellevue 
Hospital,  February,  1874. 
15" 


226  APPENDIX. 

If  Dr.  Billings's  one-story  plan  is  adopted,  we  do  not  hesitate  to 
say  that  the  hospital  would  be  a  very  great  improvement  upon  any 
other  in  this  country,  but  we  cannot  accept  his  essay  completely, 
and  sum  up  our  objections  as  follows  : 

1.  He  is  too  general  in  his  remarks  on  the  organization  and 
management  of  the  hospital. 

2.  In  his  plan  for  the  pavilions  he  does  not  recognize  the  advan- 
tage of  separating  the  ward  from  the  service-rooms,  and  favors  too 
much  the  idea  of  two  stories  under  circumstances  where  the  ques- 
tion of  sufficient  ground  cannot  arise. 

3.  His  plan  of  heating  and  ventilation,  as  he  himself  admits,  is 
an  experiment,  and  when  the  plans  are  closely  examined  we  find 
the  fresh-air  and  foul-air  ducts  placed  one  directly  above  the  other, 
so  that,  unless  at  a  great  expense  these  ducts  are  made  imper- 
meable to  air,  there  will  be  a  constant  interchange  of  their  con- 
tents ;  and  if  we  are  to  believe  the  teachings  of  Pettenkofer,  that 
almost  everything  is  permeable  to  air,  it  will  be  next  to  impossible 
to  make  the  separation  complete,  arranged  as  Dr.  Billings  has 
them. 

4.  In  his  plan  for  what  he  calls  the  third  building,  which  "  is 
to  contain  the  amphitheatre,  out-door  dispensary-rooms,  dead- 
house,  and  pathological  laboratory,"  he  violates  the  plainest  sani- 
tary law,  and  contradicts  his  own  teaching  given  in  previous 
chapters. 

5.  We  do  not  consider  his  plan  of  arranging  the  pavilions  the 
best,  either  for  the  good  of  the  patient,  or  the  convenience  and 
economy  of  administration.  It  has  the  merit  of  being  uniform 
and  well-balanced,  but  in  his  plan  for  the  one-story  pavilions 
(Plate  IV.)  these  are  too  close  to  each  other,  and  the  private 
wards  too  near  the  administrative  building. 


DR.   is^ORTON   rOLSOM'S   PLAN. 

Dr.  Folsom's  plan  for  the  pavilions,  the  wards  which  he  terms 
"  isolating  wards,"  and  the  autopsy -building,  together  with  his 
method  of  heating  and  ventilation,  is  similar  to  that  of  the 
Massachusetts  General  Hospital  now  in  use. 

The  principles  are  exactly  the  same,  but  the  details,  especially 
those  relating  to  the  administration,  are  more  elaborate  and  are  in 
many  respects  improved.     Dr.  Folsom  adopts  one  plan  for  all  his 


REVIEW  OF  DR.   FOLSOM'S  ESSAY.  227 

wards,  except  for  the  -wards  he  calls  "  isolating  wards,"  and  does 
not  speak  of  having  his  surgical  wards  differ  from  those  of  the 
medical,  and  does  not  provide  for  a  proper  classification  of  dis- 
eases. 

In  reference  to  the  training-school  for  nurses,  we  think  he  has 
misinterpreted  the  intentions  of  the  founder  when  he  proposes  to 
limit  it  to  the  use  of  the  hospital.  We  believe  that  it  was  the 
design  of  Mr.  Hopkins,  not  merely  to  afford  women  wishing  to 
become  nurses  the  opportunity  of  serving  in  that  capacity  in  the 
wards,  but  to  establish  a  training-school  in  which  the  didactic  part 
of  a  nurse's  education — of  which  Dr.  Folsom  thinks  so  little — 
should  be  begun  and  developed  until  the  profession  is  made  an 
honorable  one,  and  nurses  are  raised  above  the  level  of  servants. 

Dr.  Folsom  decides  in  favor  of  having  all  the  biAldings  in  which 
the  patients  are  treated  only  one  story  high,  but  also  decides  that 
all  parts  of  every  building  should  be  permanent  in  construction. 
To  this,  as  we  have  said  before,  we  object.  All  wards  for  acute 
surgical  and  fever  cases  should  be  so  constructed  as  to  be  readily 
destroyed  and  renewed  ;  for  other  cases  not  liable  to  become  in- 
fected, the  wards  may  "be  permanent  in  character. 

The  buildings  in  Dr.  Folsora's  plan  are  well  arranged  for  the 
convenience  of  administration,  and  so  placed  that  the  medical 
superintendent  can  readily  supervise  all  the  workings  of  the  hos- 
pital ;  but,  in  our  judgment,  the  general  plan  is  in  several  respects 
objectionable  : 

1.  The  administrative  building,  dispensar}-,  operating-theatre, 
kitchen,  laundry,  autopsy-rooms,  and  the  dead-house,  are  situated 
on  the  west  and  southwest  side  of  the  grounds,  exactly  in  the 
position  to  intercept,  during  the  summer,  when  the  windows  and 
doors  are  open,  the  prevailing  wind,  and  to  permit  the  poisoned 
atmosphere  from  these  buildings  to  be  carried  directly  into  the 
wards. 

2.  We  cannot  see  the  necessit}'  of  crowding  together  the  laun- 
dry, autopsy,  dead-house,  boilers,  and  kitchen,  nor  for  having  the 
operating-theatre  in  such  close  proximity  to  the  post-mortem 
rooms. 

3.  The  dispensary  service  and  that  of  the  hospital  are  in  com- 
mon, using  the  same  pharmacy,  etc.  Such  an  arrangement  may  do 
in  a  small  hospital,  but,  for  one  of  three  or  four  hundred  beds, 
there  will  be,  aside  from  the  necessarily  great  risk  of  infection,  and 


228  APPENDIX. 

the  unavoidable  filth  and  dirt,  much  confusion  if  the  out-patients 
are  to  use  the  same  entrance  as  the  inmates  of  the  hospital.  It  is 
obvious  that  it  would  be  difficult  to  keep  order,  if  the  out-patients, 
of  whom  nothing  is  known,  were  allowed  the  freedom  of  the 
grounds,  and  of  at  least  a  part  of  the  main  corridor  in  which  the 
attendants  are  constantly  passing.  Dr.  Folsom  recognizes  this, 
although  his  remedy  is  a  doubtful  one,  when  he  proposes  that 
red  and  blue  stripes  be  used  to  guide  the  patients  in  the  cor- 
ridors. 

A  dispensary  for  out-patients,  if  not  under  a  separate  manage- 
ment, should  at  least  be  a  distinct  department,  with  attendants, 
both  medical  and  others,  separate  from  those  of  the  rest  of  the 
hospital. 

The  plan  fqf  the  wards  adopted  by  Dr.  Folsom  is  a  great  im- 
provement on  the  two  and  three  story  buildings  so  generally  erect- 
ed, but  we  have  several  objections  to  it : 

1.  The  square-shaped  ward  would  do  very  well  for  certain  medi- 
cal cases,  but  not  for  fevers  and  acute  surgical  cases.  Compared 
with  that  usually  adopted,  in  which  the  length  is  equal  to  the 
width  multiplied  by  three,  the  wall-space  is  diminished,  obliging 
the  beds  to  be  placed  closer  together,  and  if  the  service-rooms  are 
attached  as  Dr.  Folsom  has  them,  one-third  of  the  wall-space  is  cut 
off  from  the  open  air.  Although  the  patients  are  nearer  at  hand 
and  more  equidistant  from  the  heating  apparatus  than  in  the  long 
ward,  they  are  at  the  same  time  closer  to  a  very  common  cause  of 
infection,  namely,  the  water-closets,  sinks,  etc. 

2.  There  is  no  real  separation  of  the  ward  from  the  service- 
rooms.  The  water-closets  are  very  objectionably  placed,  and  too 
few  in  number. 

3.  The  wards  are  not  on  high  basements,  the  floors  being  on 
the  same  level  as  that  of  the  corridors.  This  is  convenient  for  the 
administration,  but  we  have  never  yet  seen  a  corridor  in  which  the 
circulation  of  air  was  not  greatest  in  the  direction  of  its  length  ; 
in  fact,  we  are  satisfied  that  it  is  the  natural  direction  of  currents 
in  any  closed,  or  even  partially  closed,  narrow  and  long  spaces, 
and  that  it  is  impossible  to  prevent  these  currents  from  end  to  end 
in  corridors,  and  at  the  same  time  keep  them  warm  in  cold  weather. 
If  the  wards,  therefore,  have  direct  communication  with  the  corri- 
dor, the  foul  air  of  one  ward  mil  be  carried  to  the  others.  It  is  a 
well-known  fact  that  foul  odors  and  kitchen-fumes  are  readily  per- 


REVIEW  OF  DR.   FOLSOM'S  ESSAY.  229 

ceptible  in  corridors  at  a  distance  of  several  hundred  feet  from  the 
point  of  entrance,  although  the  windows  on  opposite  sides  of  the 
corridor  are  opened  at  several  places  between  the  two  points. 
Except  in  climates  where  the  severity  of  the  winters  absolutely 
necessitates  closed  corridors,  the  communication  between  wards 
should  be  merely  covered  ways. 

4.  The  corridors  in  Dr.  Folsom's  plan  are  objectionable,  not 
only  because  they  are  liable  to  carry  foul  air  from  one  ward  to  an- 
other, but  also  because,  on  account  of  their  height  compared  with 
that  of  the  wards,  they  will  in  a  great  measure  obstruct  the  free 
circulation  of  outside  air.  Suppose  a  wind  to  be  blowing  from  the 
southwest,  but  little  of  its  influence  would  be  felt  in  pavilions  1,  2, 
3,  and  4,  in  his  plan  on  the  north  side  of  the  grounds. 

5.  The  little  dining-room  across  the  corridor,  with  flat  tin  roof, 
only  seven  feet  high,  would  be  very  hot  in  summer. 

6.  As  Dr.  Folsom  places  his  wards  on  low  basements,  and  takes 
the  fresh  air  near  the  ground,  it  seems  that  he  has  not  considered 
the  dangers  of  ground-air,  or  that  he  does  not  give  much  weight  to 
the  late  views  of  sanitarians  on  the  subject.  If  hot  water,  heated 
b}^  a  small  furnace  attached  to  each  pavilion,  were  used  instead  of 
steam,  and  the  fresh  air  received  from  high  leads,  we  think  that 
the  method  of  heating  and  ventilation  proposed  by  Dr.  Folsom 
would  be  very  much  improved. 

7.  His  "  isolating  wards  "  would  not  be  so  objectionable  if  the 
service-rooms  were  removed  from  the  centre  and  placed  near  one 
end,  and  separated  from  the  ward  for  patients.  But  we  would 
prefer  to  have  a  small  ward  of  one  or  two  beds  in  connection  with 
the  service-rooms  of  each  pavilion,  for  the  purjDose  of  treating  cases 
not  infectious  nor  liable  to  cause  infection,  but  which  for  some 
exceptional  reason  would  be  better  removed  from  the  ward.  For 
these  wards  of  Dr.  Folsom's  another  name  than  that  of  "  isolating 
wards  "  would  be  better,  for  they  are  certainly  not  suitable  for  the 
treatment  of  such  cases  as  require  isolation  on  account  of  being 
infected  or  liable  to  cause  infection. 

Dr.  Folsom's  pavilion  for  private  patients  is  very  complete,  but 
it  would  be  better  if  the  service-rooms  were  detached,  and  we  be- 
lieve that  it  is  very  desirable  to  have  separate  buildings  for  the 
sexes,  instead  of  one  for  both  men  and  women. 

The  plan  for  the  axitopsy-building  is  very  elaborate,  and  one  of 
the  best  we  have  seen. 


230  APPENDIX. 


DR.   JOSEPH  JONES'S    PLAN. 

We  find  little  in  Dr.  Jones's  essay  that  is  original  or  valuable, 
but  he  urges  one  excellent  practice,  namely,  that  of  having  the 
wards  at  certain  intervals  thoroughly  cleansed  and  left  open  to  the 
air  and  light  for  purification.  He  recommends  that  one-twelfth  of 
the  beds  in  each  ward  and  one  in  twelve  of  all  the  wards  be  always 
left  empty. 

DR.  CASPAR   MORRIS'S   PLAN. 

The  fourth  essay,  by  Dr.  Caspar  Morris,  is  an  able  paper,  con- 
taining many  good  suggestions,  especially  in  regard  to  the  details 
of  construction  and  management,  and  is  filled  with  facts  left  untold 
by  others.  It  is,  however,  extremely  conservative  in  the  argu- 
ments against  temporary  buildings,  and  in  favor  of  solid,  two-story 
pavilions. 

On  page  200,  when  urging  the  great  necessity  of  the  utmost 
care  in  selecting  building-material,  and  in  carefully  superintending 
the  work, to  make  sure  that  it  is  well  done.  Dr.  Morris  says  :  "One 
open  seam,  or  splintered  edge  of  a  joint,  may  become  an  irremedi- 
able source  of  contamination,  in  a  ward  otherwise  without  objec- 
tion, and  thus  render  useless  all  the  expenditure  of  thought  in  con- 
triving and  money  and  labor  and  material  in  construction,  and 
make  unavailing  the  vigilance  and  neatness  of  service."  And 
again,  under  the  head  of  "  Drainage,"  page  234,  he  says  :  "  The 
v/hole  system  of  drainage  should  be  fully  planned  and  laid  out 
before  any  further  progress  is  made  in  the  arrangement  of  the 
buildings.  The  smallest  negligence  or  oversight  may  render  use- 
less the  utmost  care  and  cost  elsewhere." 

Unless  Dr.  Morris  expects  to  succeed  in  having  hospital-con- 
struction reach  perfection  and  remain  so  for  generations,  we  can- 
not understand,  after  the  above  statements,  why  he  should. recom- 
mend so  costly  a  plan  as  he  does,  and  contend  that  every  part 
should  be  solid  and  permanent  in  character.  We  do  not  say  that 
all  the  wards  of  a  hospital  should  be  of  a  temporary  character,  but 
we  repeat  that  compound  fractures,  amputations,  fevers,  and  other 
cases  liable  to  infect  a  building,  should  be  treated  in  wards  so  con- 
structed that,  at  any  time  deemed  advisable,  they  may  be  removed 
and  renewed  at  a  small  cost,  and  that  all  infected  cases  should  be 
treated  in  temporary  isolated  huts  or  tents. 


REVIEW  OF  DR.   MORRIS'S  ESSAY.  231 

In  most  hospitals  the  number  of  patients  riequiring  treatment 
in  temporary  buildings  would  not  be  large,  probably  not  more  than 
one  in  ten,  while  in  other  hospitals,  on  account  of  the  proportion- 
ally large  number  of  acute  surgical  and  fever  cases,  it  may  be 
necessary  to  have  one-fourth  of  the  wards  made  temporary.  From 
what  Dr.  Morris  says  concerning  the  EjDiscopal  Hospital  of  Phila- 
delphia, we  infer  that  not  many  such  cases  are  received  in  that 
hospital. 

The  great  advantage  as  to  the  convenience  of  administration 
and  comparatively  smaller  cost  of  the  two-story  pavilions  over  the 
one-story  plan,  so  ably  advocated  by  Dr.  Morris,  is  by  no  means 
conceded  by  all  authorities  ;  on  the  contrary,  many,  especially 
those  who  have  had  the  superintendence  of  hospitals  constructed 
on  the  one-story  plan,  state  that,  as  all  the  wards  are  on  one  level 
the  administration  is  very  much  simplified  and  more  convenient 
than  in  those  hospitals  where  there  are  stairs,  lifts,  etc.,  and  that 
the  difference  of  cost  has  been  very  much  over-estimated  ;  that 
increased  thickness  of  wall  and  strength  of  material,  together  with 
the  necessary  staircases,  lifts,  etc.,  required  in  the  tv.'o-story  j^lan, 
make  up  for  the  extra  roof  and  foundation  of  the  one-story  pavil- 
ions. 

To  give  our  objections  to  Dr.  Morris's  plan  would  be  to  reit- 
erate what  we  have  already  stated  in  our  remarks  on  the  preceding 
papers.  We  agree  with  him,  that  the  greatest  care  should  be 
given  to  the  selection  of  the  building-material,  that  the  Avorkman- 
ship  should  be  the  very  best,  and  that  bad  management,  want  of 
cleanliness,  etc.,  etc.,  will  render  useless  and  unavailing  the  best- 
constructed  hospital  ;  but  we  do  not  think  that  all  the  advantages 
afforded  by  the  one-story  buildings  can  be  attained  in  pavilions  of 
two  stories.  We  will  formulate  our  opinion  on  this  point  by  say- 
ing that,  where  the  ground-space  is  sufficient  to  permit  it,  every 
ward  of  a  hospital  should  be  in  a  separate,  one-story  building,  and 
that  acute  surgical,  fever,  and  other  cases  liable  to  infect  each 
other,  or  the  building,  should  never  be  treated  in  two-story  build- 


DR.   STEPHEN   SMITH'S   PLAK 

The  last  and,  in  many  respects,  the  best  of  the  five  essays  is 
by  Dr.  Stephen  Smith.  From  a  sanitary  standpoint  it  is  particu- 
larly interesting.     Under  the  head  of  the  "  Site  of  the  Hospital  " 


232  APPENDIX. 

he  gives  us  some  interesting  information  on  ground-air  and  ground- 
water. Accepting  the  views  of  Pettenkofer  as  to  the  evil  influ- 
ences of  ground-air  and  ground-water,  Dr.  Smith  suggests  an  elab- 
orate plan  for  draining  the  ground  of  its  air  and  water  bj  "  means 
of  a  heated  shaft  which  communicates  by  its  base  with  drain-pipes 
and  conduits  leading  to  all  parts  of  the  grounds  at  various  depths." 
Such  a  system  of  drainage  would  undoubtedly  improve  the  sani- 
tary condition  of  the  grounds,  and  make  the  soil  a  better  absorbent 
and  a  "better  disinfecter "  of  foul  gases.  To  drain  the  ground 
of  its  air  would  be  an  experiment,  and  would  cost  something, 
but  to  drain  it  of  its  water  would  be  a  simple  matter  ;  and, 
although  the  ground  may  have  many  natural  advantages,  we 
believe  that  it  would  improve  the  sanitary  condition  of  the  hos- 
pital. 

Dr.  Smith's  suggestions  on  grading  ajid  cultivation  are  valu- 
able, but  care  should  be  taken  in  planting  trees  not  to  interfere 
with  the  free  circulation  of  air. 

One  of  the  best  parts  of  Dr.  Smith's  paper  is  on  "  The  Classes 
of  the  Sick  to  be  received."  We  prefer  this  classification  of  the 
patients  to  those  given  by  the  other  essayists. 

We  accept  his  views  on  the  questions  of  temporary  versus  per- 
manent, and  one  versus  two  story  pavilions,  as  well  as  his  conclu- 
sion, page  296 — "  In  the  present  instance,  from  every  standpoint 
of  view,  we  can  but  regard  the  question  as  settled  in  favor  of  per- 
manent pavilions  of  one-story  wards  "  —  with  this  proviso,  that 
some  of  these  pavilions  should  be  in  part  temporary,  which  he  him- 
self provides  for  in  the  classification  of  his  paviHons  (page  307  of 
his  essay). 

In  many  respects  Dr.  Smith's  plan  for  his  pavilions  and  con- 
necting corridor  is  similar  to  that  of  the  paper  already  referred  to 
as  having  been  read  before  the  State  Charities  Aid  Association  ; 
but  (in  his  plans)  he  has  failed  to  carry  out  with  completeness 
some  of  the  most  important  points  of  that  plan  : 

1.  He  has  only  partially  separated  the  service-rooms  from  the 
ward  proper,  and  in  his  argument  for  this  separation  leaves  out  the 
best  reasons  for  its  adoption. 

2.  He  recommends  that  the  wards  be  placed  on  raised  base- 
ments, and  proposes  that  these  basements  should  be  closed  and 
serve  as  hot-air  chambers,  instead  of  having  the  ward  on  arches 
with  the  surface  beneath  asphalted  and  open  to  the  air  and  sun- 


REVIEW  OF  DR.   SMITH'S  ESSAY.  233 

light,  by  which  means  the  ward  would  be  in  no  danger  of  receivin"- 
the  much-dreaded  ground-air. 

3.  We  do  not  approve  of  having  the  water-closets  in  the  base- 
ments, nor  do  we  think  that  the  corridor  should  be  even  partially 
underground,  but  altogether  above  the  level  of  the  ground,  with 
the  top  not  higher  than  the  floors  of  the  wards  ;  and  it  should  con- 
nect with  the  service-rooms  on  the  outside,  and  not  pass  between 
them  and  the  ward. 

4.  If  a  second  story  to  the  service-rooms  is  needed  to  furnish 
sleeping-rooms  for  the  helpers,  a  second  story  might  be  added, 
but  we  would  not  have  any  room  up-stairs  for  the  use  of  the 
patients. 

5.  We  cannot  consider  favorably  the  method  of  heating  and 
ventilation  where  Dr.  Smith  proposes  that  the  wards  should  be 
heated  by  means  of  hot-aii'  chambers  beneath  the  ward-floor  direct- 
ly in  contact  with  the  ground.  If  such  a  system  is  adopted,  it  will 
indeed  be  necessary  to  drain  the  ground  of  its  air  ;  and  we  are  in- 
clined to  believe  that,  in  spite  of  his  carefully-constructed  base- 
ments, he  would  fail  to  prevent  these  hot-air  chambers  from  sucking 
up  a  large  share  of  the  ground-air,  thus  transmitting  it  to  the  wards, 
and  so  bringing  about  the  very  danger  he  tells  us  should  be  so  care- 
fully avoided.  We  would  much  prefer  the  well-known  and  well- 
tried  plan  of  heating  and  ventilating  by  means  of  ojDen  fires.  We 
would  supplement  these  open  fires  by  hot-water  pipes  in  small 
boxes  under  the  floor,  and  we  would  have  hot-water  pipes  so  ar- 
ranged in  the  ventilating-shaft  that  when  needed  the  hot  water 
could  be  turned  on  and  made  to  heat  the  shafts  without  warming 
the  ward.  By  means  of  these  hot-water  pipes  in  the  shafts  the 
ward  could  be  ventilated  by  suction,  during  the  disagreeable, 
murky  days  of  the  year,  when  a  fire  in  the  ward  would  be  uncom- 
fortable, and  the  necessity  of  forced  ventilation  is  so  much  felt  ; 
thus  we  would  avoid  the  expense  of  fan-ventilation. 

Dr.  Smith's  observations  on  the  defective  medical  education  of 
this  country  are  admirable,  and  ought  to  have  great  weight  as 
coming  from  a  college  professor. 

The  idea  of  having  a  chapel  used  for  school  purposes  might 
well  be  carried  out,  but  in  connection  with  the  hospital  for  con- 
valescents. 


234  APPENDIX. 

MR.   JOHN  R.   NIERNSEE'S  PLAN. 

In  the  appendix  to  the  five  essays  there  is  "  A  Description  of 
the  Plan  adopted  for  the  Johns  Hopkins  Colored  Asylum,"  and 
also  a  plan  by  John  R.  Niernsee,  the  architect  to  the  Board  of  Trus- 
tees, for  an  octagon-shaped  ward.  The  latter,  as  he  says,  is  very 
much  the  same  as  the  square  ward  adopted  by  Dr.  Folsom. 

The  octagon  ward  we  like  better  than  the  square  ward,  because 
only  one-eighth  instead  of  one-third  of  the  wall-space  is  cut  off 
from  the  outside  air  by  the  contact  of  the  service-rooms. 

The  closets  in  Mr.  Niernsee's  pavilion  are  well  placed,  and  the 
direct  communication  with  the  air  of  the  corridor  is  not  so  short  as 
in  Dr.  Folsom's  plan. 

We  heartily  agree  with  Mr.  Niernsee  in  some  of  his  conclu- 
sions, especially  three  of  them,  viz.  : 

1.  "That  hot-water  heating  is  the  most  desirable  and  effective 
mode  as  auxiliary  in  connection  with  open  fires." 

2.  Where  he  proposes  "  to  dispense  with  a  large  and  expensive 
apparatus  concentrated  in  one  place,"  and  to  have  a  small  boiler 
for  each  pavilion. 

3.  Where  he  recommends  that  the  top  of  the  corridor  should  be 
on  a  level  with  the  floor  of  the  ward,  and  serve  as  a  means  of  open 
communication  ;  but  we  would  also  raise  the  ward  high  enough  to 
enable  the  corridor  to  be  wholly  above-ground.  Air,  like  water, 
must  be  in  motion  to  keep  fresh  and  pure  ;  but  it  must  also  be 
acted  upon  by  light,  or  its  vital  qualities  will  be  greatly  dete- 
riorated. 

In  answer  to  Mr.  Niernsee's  argument  that  the  octagon  shape 
gives  more  cubic  air-space  in  proportion  to  the  wall-space  than 
the  oblong  rectangular  wards,  we  would  say  that  the  increase  of 
air-space  in  a  ward  is  not  of  great  importance  compared  with  the 
frequent,  constant,  and  complete  change  of  the  air,  and,  instead  of 
wall-space  being  a  disadvantage,  up  to  a  certain  point  it  is  very 
desirable. 

W.  Gill  Wylie. 

New  York,  December,  1875. 


At  the  same  time  that  I  sent  a  copy  of  the  above  review  to  the 
trustees  of  the  hospital,  I  forwarded  a  drawing,  giving  a  plan  for 
arranging  the  buildings  on  the  ground  almost  exactly  the  same  as 


PLAN  OF  JOUNS  HOPKINS  HOSPITAL. 


235 


that  in  the  plate,  giving  my  suggested  plan  for  a  complete  general 
hospital. 

The  following  diagram  is  taken  from  the  N^ew  York  Jledical 
Jiecord  of  March  10,  1877.     In  a  lecture,  given  to  the  medical  pro- 


FiG.  14. 


"  Block  Plan  for  Proposed  Johns  Hopkins  Hospital." 

"Explanation:  1.  Administration  Building;  2.  Pay- Wards;  3.  Kitchen;  4. 
Nurses'  Home ;  5.  Dining-Rooms  for  Medical  Officers  and  Nurses ;  6.  Pharmacy  ; 
Y.  Two-Story  Wards  ;  8.  One-Story  Wards ;  9.  Isolating  Wards ;  10.  Residence  of 
Superintendent;  11.  Dispensary;  12.  Operating-Theatre;  13.  Mortuary  Building; 
14.  Greenhouse;  15.  Laundry;  16.  Space  for  Tents." 


fession  of  Baltimore,  February  5,  1877,  by  J.  S.  Billings,  M.  D,, 
"  On  the  Plans  for  the  Johns  Hopkins  Hospital  at  Baltimore,"  this 
plan  was  shown  as  that  proposed  for  the  hospital.  Since  the  lect- 
ure we  understand  that  the  four  rectangular  wards,  adjacent  to  the 
octagonal  wards,  in  the  figure,  are  to  be  changed  into  two  pavilions 
of  two  stories,  thus  leaving  only  four  instead  of  eight  one-story 
pavilions.  We  do  not  know  the  details  of  construction  decided 
upon  ;  but  there  are  three  or  four  objectionable  points  about  the 


236  APPENDIX. 

above  plan  :  1.  The  two-storj  pavilions  ;  2.  The  position  of  the 
corridors  and  incomplete  separation  of  the  service-buildings  ;  3. 
The  so-called  isolating  wards,  similar  to  those  recommended  by 
Dr.  Folsom,  and  proximity  of  the  tents  to  the  ends  of  the  wards; 
4.  The  scattered  positions  of  the  administrative  building,  which 
will  interfere  with  easy  administration,  and  necessitates  a  huddling 
together  of  the  pavilions. 

The  plans  are  for  three  hundred  beds,  and  not  four  hundred,  as 
was  originally  intended  there  should  be. 

W.  G.  W. 


II^DEX 


Accident- ward,  152. 
Administrative-building,  149. 
Air,  119. 

Alexandrow  Hospital,  203. 
Ambulance-system,  161. 
American  RcTolution,  35. 
Apothecary-shop,  151. 
Appointments,  74. 
Architects,  10. 
Army-hospitals,  40,  177. 
Arrangement  of  the  buildings,  149. 
Asoka,  9. 

Attending  staff,  69. 
Autopsy-building,  152. 
Aztec  hospitals,  27. 

Bath-house,  151. 
Bath-rooms,  112. 
Beaujou,  184. 
Beds,  99,  131. 
Beckman,  15. 
Beekman,  J.  W.,  28. 
Bellevue  Hospital,  3,  186. 
Bellows,  Rev.  H.  W.,  47. 
Berlin  City  Hospital,  218. 
Bethanian  Hospital,  202. 
Billings,  Dr.  John  S.,  223. 
Blackburn  Infirmary,  211. 
Blackwell's  Island,  179. 
Block  plan,  194. 
Boerhaave,  22. 


Bond,  Dr.  Thomas,  29. 
Boston  Free  City  Hospital,  213. 
Bremen  Hospital,  203. 
Bristowe,  Dr.,  45. 
Brocklesby,  Richard,  23. 
Buddhist  hospitals,  9. 
Building-material,  230. 
Buildings,  92. 

Caravansaries,  12. 

Cardinal  de  Polignac,  19. 

Catholic  Hospital,  Berlin,  202. 

Charing-Cross  Hospital,  190,  188. 

Charity,  58,  68. 

Charity  Hospital,  Berlin,  202.- 

Charity   Hospital    of    New    York,    ISO, 

188. 
Chicago  Hospital,  215. 
Chorlton  Union  Hospital,  211. 
Church  hospitals,  15. 
Classification  of  hospitals,  56. 
"  "   patients,  93. 

Clinical  lectures,  158. 
Conglomerate  hospitals,  183. 
Convalescent  hospitals,  174. 
Convents,  12. 
Corridor,  114. 
Corridor  plan,  199. 
Cost  of  hospitals,  95. 
Cottage  hospitals,  139. 
Count  Rumford,  41. 


238 


INDEX. 


Crimean  War,  43. 
Cubic  air-space,  100. 

Day-room,  112. 
Desaguliers,  Jean  T.,  20. 
Dimensions  of  wards,  100. 
Dining-room,  112. 
Direct  radiation,  123. 
Disease-germs,  96. 
Disinfectants,  97. 
Dispensaries,  60,  153. 
Doors,  109. 
Drainage,  154. 

English  hospitals,  189. 

Episcopal  Hospital  of  Philadelphia,  211. 

Erichsen,  Mr.  Eric,  46. 

Essays    (published    by  Johns    Hopkins 

Hospital),  221. 
Esse,  Dr.,  218. 
Examining-room,  113. 
Extemporized  hospitals,  182. 

Fire-worshipers,  11. 
Floors,  107. 

Folsom,  Dr.  JiTorton,  226. 
Foul-air  escapes,  129. 
Foundation  of  the  ward,  104. 
Founding  hospitals,  167. 
Frankfort  Hospital,  203. 
Franklin,  Benjamin,  29. 
French  Academy  of  Sciences,  39. 
French  hospitals,  206. 
Furnaces,  123. 
Furniture,  130. 

Galton,  Douglas,  45. 
General  plan,  149,  225. 
German  Hospital  of  New  York,  214. 
German  hospitals,  47,  82,  202. 
Glasgow  Fever-Hospital,  217. 
Glasgow  Surgical  Hospital,  211. 
Grand  Hospital  of  Milan,  193. 
Guy's  Hospital,  190. 

Hales,  Stephen,  21. 

Hamburg  General  Hospital,  202. 


Hamilton,  10. 

Hand-book  for  Hospital  Visitors,  85. 

Heating,  123,  233. 

Herbert  Hospital,  210. 

Holmes,  Dr.,  45. 

Hopital  Cochin,  203. 

Hopital  St.  Jean,  206. 

Hopkins,  Johns,  221. 

Hospitalers,  13. 

Hospital  construction,  86. 

"         diseases,  86,  96. 

"        Rudolph-stiftung,  203. 
Hospitalia,  13. 
Hospitals  now  in  use,  165. 
Hotel-Dieu,  32,  183. 
House-building,  169. 
Howard,  John,  41. 
Husson,  41. 
Hut-hospitals,  44. 
Huts,  139-148. 

Impermeable  walls,  106,  120. 
Infection,  96. 
Insane-asylums,  179. 
Irregular  hospitals,  189. 
Isolatmg  huts,  139. 
Italian  hospitals,  192. 

Johns  Hopkins  Hospital,  52,  235. 
Jones,  Dr.  John,  30. 
Jones,  Dr.  Joseph,  230. 

King,  Mr.,  223. 

King's  College  Hospital,  189. 

La  Charite,  184. 
Lamothe,  14. 

La  Princesse  Hospital,  206. 
Lariboisiere,  207. 
Leeds  Infirmary,  211. 
Leon  Owens,  Mrs.,  11. 
Levy,  Michel,  44. 
Lighting  the  ward,  130. 
Lind,  James,  25. 
Linen-room,  113. 
Location  of  hospitals,  89. 
London  Hospital,  190. 


INDEX. 


239 


Lying-in  hospitals,  172. 

Management,  69-85. 
Managers,  boards  of,  69. 
Manchester  Royal  Infirmary,  203. 
Massachusetts  General  Hospital,  198. 
Material  for  building,  105. 
Maternity-wards,  160,  172. 
Medical  boards,  69. 
Medical  school,  157. 
Middlesex  Hospital,  190. 
Milan  Grand  Hospital,  15. 
Monasteries,  12. 
Monro,  Donald,  23,  25. 
Morris,  Dr.  Caspar,  230. 
Mount  Sinai  Hospital,  214. 
Muhlenberg,  Dr.  W.  A.,  200. 
Munich  General  Hospital,  192. 

Natural  ventilation,  119. 
Neirnsee,  John  R.,  234. 
New  York  City  hospitals,  58,  213. 
New  York  Hospital,  Old,  30. 
■     "       "  "         New,  35,  198. 

New  York   Training-School  for  Nurses, 

79. 
Nightingale,  Florence,  44. 
Nurses,  162. 
Nurses'  room,  113. 

One-story  pavilion  plan,  49,  215. 
Open  fires,  119,  124. 
Operating-theatre,  151,  158. 
Organization,  69-85. 
Origin  of  hospitals,  1-55. 
Out-door  dispensary,  153. 
Out  of  two  hospitals,  174. 

Paris  hospitals,  32. 

Pathological  building,  152. 

Pathological  room,  159. 

Pauper  hospitals,  64. 

Pauperism,  relation  to  hospitals,  57. 

Pay-patients,  134. 

Pay-wards,  136. 

Pavilion  hospitals,  26. 

Pavilion  plan,  205. 


Pennsylvania  Hospital,  20,  198. 
Permanent   or   temporary  hospitals,  96, 

120. 
Pettenkofer,  98. 
Phelps,  J.  W.,  28. 
Piazza,  109. 

Plan  for  small  hospital,  170. 
Post-mortem  room,  159,  225. 
Preparation  of  the  grounds,  91. 
Presbyterian  Hospital  of  New  York,  214. 
Presbyterian   Hospital  of   Philadelphia, 

215.  • 

Prescott,  27. 
Pringle,  Sir  John,  23. 
Provident  dispensaries,  135. 

Reception-hospitals,  161. 
Repairing  old  hospitals,  165. 
Report  of  committee  of  French  Acade- 
my, 39. 
Rhode  Island  Hospital,  214. 
Roof,  109. 

Roosevelt  Hospital,  214. 
Rotherham  Hospital,  218. 
Rotterdam  Hospital,  203. 
Royal  Infirmary  of  Edinburgh,  195. 
Rush,  Dr.,  36. 

St.  Andre  General  Hospital,  206. 

St.-Antoine,  184. 

St.  Bartholomew,  190. 

St.  Luke's  Hospital,  200. 

St.  Thomas's  Hospital,  209. 

San  Francisco  Hospital,  215, 

Sanitary  Commission,  U.  S.,  47. 

Scavoneur,  10. 

Service-rooms,  102,  110,  224. 

Sewers,  154. 

Sunpson,  Sir  J.  Y.,  40. 

Site  for  hospital,  89. 

Small  hospitals,  166. 

Smith,  Dr.  Stephen,  231. 

Special  huts,  130-148. 

Stable,  152. 

State  Charities  Aid  Association,  79,  188. 

Statistics,  4,  5. 

Steam  coils,  124. 


240 


INDEX. 


Stonehouse  Hospital,  26,  206. 
Stoves,  123. 
Students,  1.58. 
Superintendent,  80-85. 
Sutherland,  Dr.  John,  45. 
Swete,  Horace,  52. 

Tenon,  41. 

Tilton,  Dr.  James,  37. 

Toner,  Dr.,  13. 

Town  hospitals,  166. 

Training-school  for  nurses,  162. 

Trustees,  168. 

University  College  Hospital,  191. 

Urinals,  131. 

United  States  Marine  Hospital,  217. 

Valetudinarians,  12. 


Van  Swieten,  Gerard,  22,  24. 
Ventilation,  19,  118,  126,  233. 
Vienna  General  Hospital,  192. 

"Wards,  94. 

Warming,  123. 

Washington,  General  George,  36. 

Wash-room,  111. 

Water-closets,  111. 

Water-supply,  154. 

Watson,  Dr.  John,  11. 

Windows,  108. 

Wise,  Thomas  A.,  10. 

Woman's  Hospital  of  New  York  State, 

213. 
Women's  influence,  77. 

Zeudocliia,  13. 


THE   END. 


\ 


DESCRIPTIVE  CATALOGUE 

/  OK 

MEDICAL    WORKS. 


iisriDKx:  OF  sxjBjicaTS. 


Anatomy 10 

Anaesthesia 26 

Acne 4 

Body  and  Mind 18 

Breatli,  and  Diseases  which  give  it  a  Fetid 
Odor 16 

Cerebral  Convolutions 7 

Chemical  Examination  of  the  Urine  in  Dis- 
ease      8 

Chemical  Analysis 14 

"        Technology 81 

Chemistry  of  Common  Life IT 

Clinical  Electro-Therapeutics 12 

"       Lectures  and  Essays 24 

Comparative  Anatomy G 

Club-foot 27 

Diseases  of  the  Nervous  Svstem 10,  12,  13 

' Bones ". 20 

"         "  Women 2«,  2T 

"        "  the  Chest 20 

"         "  Children 25,  29 

"  the  Rectum.. 28 

"         "    "    Ovaries 31 

Emergencies 15 

Electricity  and  Practical  Medicine 19 

Foods 27 

Galvano-Therapeutics 20 

Hospitalism 26 

Histology  and  Histo-Chemistry  of  M.in 8 

Infiincy 6 

Insanity  in  its  Relation  to  Crime 12 

Materia  Medica  and  Thetapeuties 5.  2i 

Medical  Journal -"i 

AldDtal  Physiology C 


PAGK 

Midwifery 26,  27 

Mineral  Springs 80 

Neurala:ia 2 

Nervous  System 12,  13 

Nursing 22 

Obstetrics 3,  7,  26,  27 

Ovarian  Tumors 23 

"       Diagnosis  and  Treatment 80 

Paralvsis  from  Brain-Disease 8 

Physiology 6,  9,  10, 1 1 

Physiology  of  Common  Life 17 

Physiology  and  Pathology  of  the  Mind 18 

Physiological  Effects  of  Severe   Muscular 

E.xercise 12 

Pulmonary  Consumption 4 

Practical  Medicine 21 

Physical  Cause  of  the  Death  of  Christ 26 

Popular  Science 32 

Puerperal  Diseases 2 

Reports 24 

Recollections  of  Past  Life 15 

"  of  the  Army  of  the  Potomac.  17 

Responsibility  in  Mental  Diseases 18 

Sea-Sickness 3 

Surgical  Pathology 4 

"      Diseases  "of  the  Male  Genito- Uri- 
nary Organs     28 

Surgery,  Conser%-ative 2 

'•         Orthopedic 25 

Syphilis 23 

Science 32 

Skin-Diseases 23 

Therapeutics 6 

Uterine  Therapeutic'.^ 27 

Winter  and  Spring 4 


D.  APPLETON  &  CO., 

PUBLISHERS    AND     IMPORTERS, 

549  &-  551  BJ^OADIVAY,  NEW  YORK. 
1870. 


2  D.  Appleton  <&  Co.^s  Medical  Publications. 

ANSTIE. 

IN  CUr3.1^13-,  and  Diseases  which  resemble  it. 

By  FRANCIS  E.  ANSTIE,  M.  D.,  F.  R.  C.  P., 

Senior  Assistant  Physician  to  Westminster  Hospital ;  Lecturer  on  Materia  Medlca  In  ■West- 
minster Hospital  School ;  and  Physician  to  the  Belgrave  Hospital  for  Children ;  Editor  of 
"The  Practitioner"  (London),  etc. 

1  vol.,  12mo.    Cloth,  $2.50. 

"  It  13  a  valuable  contribution  to  scientific  medicine."—  The  Lancet  (^London). 

BARKER. 
The  Puerperal  Diseases.     cHnicai  zectures 

delivered  at  £ellevue  Hospital. 

By  FORDYCE  BARKER,  M.  D., 

Clinical  Professor  of  Midwifery  and  the  Diseases  of  Women  in  the  Bellevue  Hospital  Medical 
College;  Obstetric  Physician  to  Bellevue  Hospital;  Consulting  Physician  to  the  New  York 
State  Women's  Hospital ;  Fellow  of  the  New  York  Academy  of  Medicine ;  formerly  Presi- 
dent of  the  Medic.ll  Society  of  the  State  of  New  Yorlc;  Honorary  Fellow  of  the  Obstetrical 
Societies  of  London  and  Edinburgh;  Honorary  Fellow  of  the  Eoyal  Medical  Society  of 
Athens,  Greece,  etc.,  etc.,  etc. 

Third  Edition.    1  vol.,  8vo.    Cloth.    526  pages.    Price,  $5  ;  Sheep,  $6. 

"For  nearly  twenty  years  it  h.is  been  my  duty,  as  well  as  my  privilege,  to  give  clinical  lect- 
ures at  Bellevue  Hospital,  on  midwifery,  the  puerperal  and  the  other  diseases  of  women.  This 
volume  is  made  up  substantially  from  phonographic  reports  of  the  lectures  which  I  have  given 
on  the  puerperal  diseases.  Having  had  rather  exceptional  opportunities  for  the  study  of  these 
diseases,  I  have  felt  it  to  be  an  imperative  duty  to  utilize,  so  far  as  lay  in  my  power,  the  advan- 
tages which  I  have  enjoyed  for  the  promotion  of  science,  and,  I  hope,  for  the  interests  of  human- 
ity. In  many  subjects,  such  as  albuminuria,  convulsions,  thrombosis,  and  embohsm,  septicfemia, 
and  pyaemia,  the  advance  of  science  has  been  so  rapid  as  to  make  it  necessary  to  teach  something 
new  every  year.  Those,  therefore,  who  have  formerly  listened  to  my  lectures  on  these  subjects, 
and  who  now  do  me  the  honor  to  read  this  volume,  will  not  be  surprised  to  find,  in  many  par- 
ticulars, changes  in  pathological  views,  and  often  in  therapeutical  teaching,  from  doctrines  before 
inculcated.  At  the  present  d.'iy,  for  the  first  time  m  the  history  of  the  world,  the  obstetric  depart- 
ment seems  to  be  assuming  its  proper  position,  as  the  highest  branch  of  medicine,  if  its  rank  be 
graded  by  its  importance  to  society,  or  by  the  intellectual  culture  and  ability  required,  as  com- 
pared with  that  demanded  of  the  physician  or  the  surgeon.  A  man  may  become  eminent  as  a 
physician,  and  yet  know  very  little  of  obstetrics;  or  he  may  be  a  successful  and  distinguished 
surgeon,  and  be  quite  ignonant  of  even  the  rudiments  of  obstetrics.  But  no  one  can  be  a  really 
able  obstetrician  unless  he  be  both  physician  and  surgeon.  And,  as  the  greater  includes  the  less, 
obstetrics  should  rank  as  the  highest  department  of  our  profession." — From  Avthor'a  Preface, 

On  Sea-Sickness,  by fordyce  barker,  m.  d. 

1  vol.,  16mo,    36  pp.    Flexible  Cloth,  76  cents. 

Reprinted  from  the  New  York  Medical  JotrRNAL.  By  reason  of  the  great  demand  for  th« 
number  of  that  journal  containing  the  paper,  it  is  now  presented  in  book- form,  with  such  pre* 
acriptions  added  as  the  author  has  found  useful  in  relieving  the  suflferlng  from  sea-sickness. 

BUCK. 
Contributions  to  Reparative  Surgery: 

Showing  its  A2)plication  to  the  Treatment  of  Deformi- 
ties, produced  by  Destructive  Disease  or  Injury  •  Con- 
genital  Defects  from  Arrest  or  Excess  of  Development  / 
and  Cicatricial  Contractions  from  Burns. 

By  GURDON  buck,  M.  D. 
Illustrated  hy  Numeroas-  Engravings.    1  vol.,  8vo. 


D.  Appleton  <jb   6^0. '*•  Medical  Publications.  3 

BARNES. 

Obstetric  Operations,  including  the  Treatment  of 
JTcpjiiorrhage,  and  forming  a  Guide  to  the  3fanagement 
of  Difficult  Labor. 

Br  ROBERT  BARNES,  M.  D.,  London,  F.  R.  C.  P., 

Obstetric  Physician  and  Lecturer  on  Obstetrics  and  the  Diseases  of  Women  and  Children  to  St. 
Georpe'8  Hospital ;  Examiner  in  Obstetrics  to  the  Royal  College  of  Physicians  and  tlic  Itoyal 
College  of  Surgeons;  President  of  the  Metropolitan  Branch  of  the  British  Medical  Assoi'ia- 
tion;  late  Examiner  to  the  University  of  London  ;  formerly  Obstetric  Physician  to  tlic  Lon- 
don and  to  St.  Thomas  Hospitals ;  and  late  Physician  to  the  Eastern  Division  of  the  K'oyal 
Maternity  Charity. 

Third  Edition.    Revised  and  extended.    1  vol.,  8vo.    606  pages.    Cloth,  $4.50. 

"  Such  a  work  as  Dr.  Barnes's  was  greatly  needed.  It  is  calculated  to  elevate  the  practice  of 
the  obstetric  art  in  this  country,  and  to  be  of  great  service  to  the  practitioner." — Lancet. 

"The  book  of  Dr.  Barnes  is  not  properly  spe.aking,  a  dogmatic  treatise  on  obstetric  opera- 
tions. It  is  a  series  of  original  lectures,  comprising,  at  one  and  the  same  time,  a  piractical  analvisis 
of  the  serious  accidents  in  parturition,  the  reasoned-out  indications  for,  and  the  most  judicious 
researches  iu  the  manner  of  operating,  the  method  to  choose,  the  instrument  to  prefer,  and  the 
detaiKs  of  the  manoeuvres  required  to  insure  success.  The  clearness  of  the  style  is  perfect.  The 
order,  without  being  altogether  rigorous,  is  what  it  is  able  to  be  generally  in  a  seriis  of  clinical 
lectures.  The  description  of  the  instruments,  the  application  of  the  forceps,  cephtilotripsy,  em- 
bryotomy, Cissarean  section,  the  practical  reflections  on  narrowing  and  malformation  of  the  pel- 
vis, ruptures  of  the  uterus,  jilaoenta  prfevia,  hiemorrhage,  and,  in  fact,  all  the  grand  questions  in 
obstetrics  are  treated  with  accurate  good  sense.  At  each  instant,  by  some  remark  or  other,  is 
revealed  a  superior  mind,  ripened  by  having  seen  much  and  meditated  much." — From  Preface 
to  the  French  Edition  by  Prof.  Pajot. 

BASTIAN. 
Paralysis    from    Brain    Disease    in    its    , 

Common  Forms. 

By  H.  CHARLTON  BASTIAN,  M.  A.,  M.  D.,  F.  R.  S., 

Fellow  of  the  Royal  College  of  Physicians ;  Professor  of  Pathological  Anatomy  in  University 
College,  London;  Physician  to  LTniversity  College  Hospital;  and  Senior  Assistant  Physician 
to  the  National  Hospital  for  the  Paralyzed  and  Epileptic. 

"With  Illustrations.    1  vol.,  12mo.    Cloth.    Si. 75. 

PREFACE. 

These  Lectures  were  delivered  in  University  College  Hospital  last  ye.ir,  at  a  time  when  I  was 
doing  duty  for  one  of  the  senior  physicians,  and  daring  the  same  year — after  they  had  been  re- 
produced from  very  full  notes  taken  by  my  friend  Mr.  John  Tweedy — they  appeared  in  the  pages 
of  T/ie  Lancet. 

They  are  now  republished  at  the  request  of  many  friends,  though  only  after  having  undergone 
a  very  careful  revision,  during  which  a  considerable  quantity  of  new  matter  has  been  added.  It 
would  have  been  easy  to  have  very  much  increased  the  size  of  the  book  by  the  introduction  of  a 
larger  number  of  illustrative  cases,  and  by  treatment  of  many  of  the  subjects  at  greater  length, 
but  this  the  author  has  purposely  abstained  from  doing,  under  the  belief  that  in  its  present  form 
it  is  likely  to  prove  more  acceptable  to  students,  and  also  perhaps  more  useful  to  busy  practi- 
tioners. 

Kotwithstanding  its  defects  and  many  shortcomings,  the  author  is  not  without  a  hope  that 
this  Uttle  book  may  be  considered  in  some  measure  to  supply  a  deficiency  which  has  long  existed 
In  medical  literature.  No  department  of  medicine  stands  more  in  need  of  being  represented  in 
a  text  book  of  moderate  compass;  so  that,  imperfect  as  it  is.  this  small  work  may  perhaps  be  of 
some  service  till  it  is  superseded  by  something  better.  In  it  the  author  has  endeavored  to  treat 
the  subject  with  more  precision  than  has  hitherto  been  customary,  and,  while  the  lectures  contain 
some  novelties  in  method  and  mode  of  exposition,  he  hopes  they  may  also  be  found  not  unfaitli- 
fuUy  to  embody  the  principal  facts  at  present  known  concerning  this  very  Important  class  of 
diseases. 


4  D.  Appleton  <&  Co.^s  3Iedical  Tuhlications. 

BENNET. 
On  the  Treatment  of  Pulmonary  Con- 

sionption,  by  Hygiene^    Climate^   and  Medicine^  in  its 
Connection  with  Modern  Doctrines. 

Bt  JAMES   HENRY   BENNET,  M.  D., 

Member  of  ihe  Royal  College  of  Phyeicians,  London  ;  Doctor  of  Medicine  of  the  Univertlty  of  Paris,  etc.,  etc. 

1  vol.,  tMn  8vo.    Cloth,  $1.50. 

An  interesting  and  instmctive  work,  written  in  the  strong,  clear,  and  lucid  manner  which  appean  In  all  tbo  con- 
tributions of  Dr.  Bennet  to  medical  or  general  literature. 

'•  We  cordially  commend  this  book  to  the  attei.tion  of  all,  for  its  practical  common-iens«  views  of  the  nature  and 
treatment  of  the  scourge  of  all  temperate  climates,  pulmonary  consumption," — JDetroii  Review  of  Medicine, 

Winter  and  Spring  on  the  Shores  of 

the    Mediterranean ;    or,   the    Jiiviera,   Mentone,   Italy, 
Corsica,  Sicily,  Algeria,  JSpc'',.,  and  Biarritz,  as  Win- 

t^r  Climates. 

'ims  work  enibodies  the  experience  often  winters  and  sj'rin;f<i  pasrrd  By  Dr.  Bennet  on  the  ihorei  of  the  Mediter- 
ranean, and  coutaini  much  ralualle  information  for  physici::u.  .a  relatiuo  to  Ihe  health  restoring  climate  of  there- 
erions  described. 

1  vol.,  12mo     'i5i  pp.    Cloth,  $3.nC. 

"  Exceedingly  readable,  apart  from  its  special  purposes,  and  well  illustrated." — Erenivp  C"y»niercxal, 
**  It  has  a  more  aubatantial  value  for  the  physician,  j>erha^s,  than  for  any  other  class  or  profesaion.  .  .  .  We  com- 
mend this  book  to  our  readers  as  a  Tolume  pref^nting  two  capital  qualificatiuns — it  ii  at  ouce  eott^rtaiuing  and  iaitrao* 
tive."— i^,  y.  MedicalJournal 

BILLHOTH. 
General  Surgical  Pathology  and  The- 

rapeutics,  in  I'^ifty  Ziccturcs.     A  Text-hook  for  Students 
and  Physicians. 

By  Db.  THEODOR   BILLROTH. 

Translated  from  the  Fifth  German  Edition,  with  the  special  permission  of  the  Author,  by 
CHARLES  E.   HACKLEY,  A.  M.,  M.  D., 

Surgeon,  to  the  New  York  Eye  and  Ear  Infirmary ;  PLvfiician  to  the  New  York  Hospital ;  Fellow  of  the  New  York 

Academy  of  Medicine,  etc. 

^  vol.,  8vo.    714  pp.,  and  152  Woodcuts.    Cloth,  $5.00;  Sheep,  $6.00. 

Professor  Theodor  Billroth,  one  of  the  most  noted  authorities  on  Surpical  I'atholoj^,  gives  in  this  volume  a  compleU 
ritume  of  the  existing  state  of  knowledge  lu  this  branch  of  medical  science.  Tlie  fact  of  this  publication  going  throogh 
four  editions  in  Germauy,  and  having  been  translated  into  French,  Italian,  Kuaaian,  and  irungarian,  should  be  somt 
guarantee  for  its  standing. 

*'  The  want  of  a  bnriV  In  the  English  language,  presenting  in  a  concise  form  the  views  of  the  German  patfaologlftAy 
has  long  beeri  fell  ;  and  we  venture  to  sav  no  dook  could  nmre  perfectly  supply  that  want  than  tlie  present  volum** 
.  .  .  We  would  itrungly  recommend  it  to  all  who  take  any  interest  in  the  progress  of  thought  and  ob&«;rvatiun  in  soi^* 
cal  patiiology,  and  surgery-" — The  Lancet. 

^'  We  can  assure  our  readers  that  they  will  consider  neither  money  wasted  In  it£  purchase,  nor  time  In  Its  penuaL" 
— 77(<  Medical  InvuligalOT, 

BULKLEY. 

Acne ;  its  Pathology,  Etiology,    Prog- 

nosis,  and  Treatment. 

By  L.  DUNCAN  BULKLEY,  A.  M.,  M.  D., 

New  York  Hospital. 

A  monograph  of  about  seventy  pages,  illustrated,  founded  on  an  analj- 
sis  of  two  hundred  cases  of  various  forms  of  Acne.     {In  x>rcss.) 


I).  Appleton  <&  Co.''s  Medical  Publications.  6 

BARTHOLOW. 

A  New  Scientific  and   Practical  Work 

on  Materia  Medica  and  Therapeutics. 

By  ROBERTS  BARTHOLOW,  M.  A.,  M.  D., 

Professor  of  the  Theory  and  Practice  of  Medicine,  and  of  Clinical  Medicine,  and  formerly  Profesa- 
or  of  Materia  Medica  and  Therapeutics  in  the  Medical  College  of  Ohio;  Physician  to  the 
Hospital  of  the  Good  Samaritan:  Corresponding'  Member  of  the  New  York  Neurological 
t^ociety ;  Author  of  a  Manual  of  llypodermie  Medication,  of  the  Russell  Prize  Essay  on 
Quinine,  of  the  American  Medical  Association  Prize  Essay  on  Atropia,  and  of  the  Fiske  Fund 
',    Prize  Essay  on  the  Bromides,  etc. 

One  vol.,  8vo.    Cloth.    548  pages.    Price,  $5.00. 


In  this  work,  a  volume  of  moderate  compass,  is  condensed  the  whole  subject 
of  Materia  Medica  and  Therapeutics,  less  Ih^  botanical  and  chemical  details.  The 
author  his  included  just  that  kind  of  infor.nation  which  is  required  by  the  student 
and  praclilioncr,  and  has  omitted  all  tliose  details  now  universally  commitied  to 
the  'iiug'^ist  and  apothecary.  Thj  official  names  of  iudividual  remedies,  and  the 
German  and  French  synonyms,  are  first  given ;  then  follows  the  list  of  pharma- 
ceutical preparations,  the  composition  of  these  and  the  doses;  next  the  antago- 
nists and  incompatibles,  and  the  synergists.  The  author  gives  a  full  account  of 
the  physiological  actions  and  the  therapeutical  applications  of  remedies,  and  he 
is  especially  full  and  explicit  on  these  important  topics.  As  he  states  in  his 
preface :  "  In  describing  the  physiological  action  of  drugs,  two  methods  may  be 
pursued :  to  present  in  chronological  order  a  summary  of  the  opinions  of  various 
authorities  on  the  subject  in  question ;  or  to  condense  in  a  connected  description 
that  view  of  the  subject  which  seems  to  the  author  most  consonant  with  all  the 
facts.  I  have  adopted  the  latter  plan,  from  a  conviction  of  its  advantages  for  the 
student,  and  of  its  utihty  for  the  practitioner." 

The  utmost  brevity  consistent  with  clearness  is  kept  in  view  throughout.  A 
very  considerable  portion  of  the  book  is  devoted  to  the  therapeutical  applications 
of  remedies.  The  author  states  on  this  point :  "  As  respects  the  therapeutical 
applications  of  remedies,  I  have,  as  far  as  practicable,  based  them  on  the  physio- 
logical actions.  Many  empirical  facts  are,  however,  well  founded  in  professional 
experience.  Although  convinced  that  the  most  certain  acquisitions  to  therapeu- 
tical knowledge  must  come  through  the  physiological  method,  I  am  equally  clear 
that  well-established  empirical  facts  should  not  be  omitted,  even  if  they  are  not 
explicable  by  any  of  the  known  physiological  properties  of  the  remedies  under 
discussion."  The  practitioner  will  find  in  the  therapeutical  portion  of  the  work 
numerous  valu.ible  formulae,  adapted  to  the  exigencies  of  practice. 

This  treatise  discusses  subjects  not  heretofore  introduced  into  therapeutical 
works.  The  chapter  on  Aliment  is  quite  full,  and  includes  such  topics  as  animal 
and  vegetable  aliment,  special  plans  of  diet,  denutrition,  dry  diet,  vegetable  diet, 
animal  diet,  milk-diet,  alimentation  in  acute  diseases,  in  cachectic  diseases,  nutrient 
cnemata,  etc.  The  importance  of  knowledge  on  these  subjects  can  hardly  be 
over-estimated. 

Part  I.  treats  of  "the  modes  in  which  medicines  are  introduced  into  the  orjfanism." 
Part  II.  treats  of  "'the  actions  and  uses  of  remedial  .a^euts."  under  the  severil  subdivistona 
of  "ag-ents  promotins:  constructive  metamorphosis,"  "agents  promoting  destructive   metamor- 
phosis," '•  agents  used  to  modify  the  functions  of  the  nervous  system,"  and  "  agents  used  to  causd 
some  ev.icu.itiou  from  the  body." 

Part  III.  treats  of  "  topical  remedies,"  and  includes  such  topics  as  "  Antiseptics,"  "  Counter- 
irritants."  '•  Epispastics."  '•  .\cupuricture,"  "Uaunsclieldtismus,"  " Aquapuncture,"  "Bloodlet- 
ting," " Escharotics,"  "Emollients,  Demulcents,  and  Protectives." 

Scarcely  any  topic  in  therapeutics  fails  to  receive  attention,  and  all  are  dis- 
cussed with  great  conciseness,  but  clearly  aud  adequately. 


6  D.  Appleton  <&    Co.^s  3fedical  Puhlications. 

CARPENTER 
Principles   of   Mental    Physiology,  wuh 

their  Applications  to  the  Training  and  Discipline  of  the 
Mind  and  the  Study  of  its  Morbid  Conditions. 

By  WILLIAM  B.   CARPENTER,  M.  D.,  LL.  D.,  F.  R.  S.,  F.  L.  S.,  F.  G.  S., 

Begistrar  of  the  University  of  London  j  Corresponding  Member  of  the  Institute  of  France  and  of  the  American  FMIo»- 

aophical  Society,  etc. 

1  vol.,  8vo.    Price,  $3.00. 

**  Among  the  numerous  eminent  writers  this  country  has  produced,  none  are  more  deserving  of  praise  for  having  at- 
tempted to  apply  the  results  of  Physiological  Research  to  the  explination  of  the  mutuil  relations  of  the  mind  and 
body  than  Dr.  Carpenter.  To  him  belongs  the  merit  of  having  scientifically  studied  and  of  having  in  many  inatancet 
Bupplied  a  rational  explanation  of  those  phenomena  which,  under  the  names  of  mesmerism,  spirit-rapping,  electro- 
biology,  and  hypnotism,  have  attracted  so  large  ao  amount  of  attention  during  the  last  twenty  years.  .  ,  .  We  must 
conclude  by  recommending  Dr.  Carpenter's  work  to  the  members  of  our  own  profession  as  applying  many  facts,  tliat 
have  hitherto  stood  isolated,  to  the  explanation  of  the  functions  of  the  brain  and  to  psychological  processes  generally." 
—The  Lancet, 

COMBE. 

The  Management  of  Infancy,  physiologi- 
cal and  Moral.  Intended  chiefly  for  the  Use  of 
Parents. 

By   ANDREW   COMBE,  M.D. 
REVISED  AND  EDITED 

Bt  Sir  JAMES  CLARK,  K,  C.  B.,  M.  D.,  F.  R.  S., 

Physician-iB-ordmary  to  the  Queen. 

First  American  from  the  Tenth  London  Edition.     1   vol.,  12mo.     302  pp. 

Cloth,  S1.50. 

"This  excellent  little  book  should  be  in  the  hand  of  every  mother  of  ft  family;  and,  If  some 
of  our  lady  friends  would  master  its  contents,  and  either  bring  up  their  children  by  the  light  of 
Its  teachings,  or  communicate  the  truths  it  contains  to  the  poor  tjy  whom  they  are  surrounded, 
we  are  conyinced  that  they  would  efl'ect  infinitely  more  good  than  by  the  distribution  of  any 
nmnber  of  tracts  whatever.  .  .  .  We  consider  this  work  to  be  one  of  the  few  popular  medical 
treatises  that  any  practitioner  may  recommend  to  his  patients;  and,  though,  if  its  precepta  are 
followed,  he  will"  probably  lose  a  few  guineas,  he  will  not  begrudge  them  if  he  sees  his  friend's 
children  grow  up  healthy,  active,  strong,  and  both  mentally  and  physically  capable." — Tha 
Lancet. 

CHAUVEAU. 
The    Comparative    Anatomy    of    the 

Domesticated  Animals. 

By  a.  CHAUVEAU, 

PEOFESSOE   AT  THE   LTONS   TETEEINAET   SCHOOL. 

Second  edition,  revised  and  enlarged,  with  the  cooperation  of  S.  ARLOING, 
late  Principal  of  Anatomy  at  the  Lyons  Veterinary  School ;  Professor  at  the 
Toulouse  Veterinary  School.  Translated  and  edited  by  GEORGE  FLEMING, 
F.  R.  G.  S.,  M.  A.  I.,  Veterinary  Surgeon,  Royal  Engineers. 

1  vol.,  8vo.    Cloth.    957  pp.,  with  450  Illustrations.    Price,  $6.00. 


D.  Applet  on  cfc  Co. '5  Medical  Ihcblications.  ^ 

DAVIS. 

Conservative  Surgery,  as  exhibited  in  remedying 
some  of  the  Mechanical  Causes  that  operate  injuriously 
both  in  Health  and  Disease.     With  Ilhcstrations. 

By  HENRY  G.  DAVIS,  M.  D., 

Member  of  the  American  Medical  Association,  etc,  etc. 
1  vol.,  8vo.    315  pp.    Cloth,  $3.00. 

The  author  has  enjoyed  rare  facilities  for  the  study  and  treatment  of  certain  classes  of  disease, 
«nd  the  records  here  presented  to  the  profession  are  the  gradual  accuuiulation  of  over  thirty 
years'  Investigation. 

"Dr.  Davis,  bringing,  as  he  does  to  his  specialty,  a  great  aptitude  for  the  solntlon  of  mechani- 
cal problems,  takes  a  high  rank  as  an  orthopedic  surgeon,  and  his  very  practical  contribution  to 
the  literature  of  the  subject  is  both  valuable  and  opportune.  We  deem  it  worthy  of  a  place  In 
every  physician's  library.  The  style  is  unpretending,  but  trenchant,  graphic,  and,  best  of  all, 
<iulte  intelligible."— Jfisdtca/  Record. 

ECKER 
The   Cerebral    Convolutions   of  Man, 

represented  according  to  Personal  Investigations^  espe- 
cially on  their  Development  in  the  Foetus^  and  with  ref- 
erence to  the  Use  of  Physicians. 

By  ALEXANDER  ECKER, 

Professor  of  Anatomy  and  Comparative  Anatomy  in  the  University  of  Freiburg. 

Translated  from  the  German  by  Robert  T.  Edes,  M.  D. 

1  vol.,  8vo.    87  pp.    $1.25. 

"The  work  of  Prof.  Ecker  is  noticeable  principally  for  its  succinctness  and  clearness,  avoiding 
long  discussions  on  undecided  points,  and  yet  sufficiently  furnished  with  references  to  make  easy 
its  comparisons  with  the  Ial)ors  of  others  in  the  same  direction. 

"Entire  originality  in  descriptive  anatomy  is  out  of  the  question,  but  the  facts  verified  by  out 
author  are  here  i>resented  in  a  more  intelligible  manner  than  in  any  other  easily-accessible  work. 

"The  knowledge  to  be  derived  from  this  work  is  not  furnished  by  any  other  text-book  in  tlM 
English  language."— JSoston  Medical  and  Surgical  Journal,  January  20, 1878. 

ELLIOT. 

Obstetric  Clinic,  a  Practical  contribution  to  the  Studi/ 
of  Obstetrics^  and  the  Diseases  of  Women  and  Children, 
By  the  late  GEORGE  T.  ELLIOT,  M.  D., 

Late  Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  the  Bellevne  TTospItal 
Medical  College ;  Physician  to  Bellevue  Hospital  and  to  the  New  York  L>-ing-ln  Asylum; 
Consulting  Physician  to  the  Nurserj*  and  Child's  Hospital ;  Consulting  Surgeon  to  the  Stat« 
■Woman's  Hospital ;  Corrcsfionding  Member  of  the  Edinburgh  Obstetrical  Society  and  of  th« 
Royal  Acaileiny  of  Havana;  Fellow  of  the  N.  Y.  Academy  of  Medicine;  Member  of  th0 
County  Medical  Society,  of  the  Pathological  Society,  etc.,  etc. 

1  vol.,  8vo.    458  pp.    Cloth,  $4.50. 

This  work  Is,  in  a  measnre.  a  resume  of  separate  papers  previously  prepared  by  the  lat«  Df. 
Elliot;  and  contains,  besides,  a  record  of  nearly  two  hundred  Important  and  difficult  cases  in  mid- 
wifery, selected  from  his  own  practice.  It  baa  met  with  a  hearty  reception,  and  haa  received  th« 
highest  encomiums  both  in  this  country  and  in  Europe. 


8  D.  Appleton  &  Co.^s  Medical  l^ublications, 

PREY. 
The    Histology  and    Histo-Chemistry 

of  Man.     A  Practical  Treatise  on  the  Elements  of  Com' 
position  and  Structure  of  the  Hitman  Body. 

By  HEINKICH  FREY, 

Professor  of  Medicine  fti  Zurich. 

Translated  from  the  Fourth  German  Edition,  by  Arthur  E.  J.  Barker, 

Surgeon  to  the  City  of  Dublin  Hospital;  Demonstrator  of  Anatomy,  Koyal  Colleg'o  of  Surgeona, 
Ireland ;  Visiting  Surgeon,  Convalescent  Uome,  Stillorgan ;  and  re\ised  by  the  Author. 
"With  C80  Engravings. 

1  vol.,  8vo.    Cloth,  $5.00 ;  Sheep,  $6.00. 

CONTENTS. 
The  Elements  of  Composition  and  of  Structure  of  the  Body :  Elements  of  Composition— Al- 
buminous or  Protein  Compounds,  IIa>moglobulin,  Ilistogenic  Derivatives  of  the  Albuminous 
Substances  or  Albuminoids,  the  Fatty  Acids  and  Fats,  the  Carbohydrates,  Non-Nitrogenous 
Acids,  Nitrogenous  Acids,  Amides,  Amido-Acids,  and  Organic  Bases,  Animal  Coloring  Matters, 
Cyanogen  Compounds,  Mineral  Constituents;  Elements  of  Structure— the  Cell,  the  Origin  of  the 
Remaining  Elements  of  Tissue ;  the  Tissues  of  the  Body — Tissues  composed  of  Simple  Cells,  with 
Fluid  Intermediate  Substance,  Tissues  composed  of  Simple  Cells,  Avith  a  small  amount  of  Solid 
Intermediate  Substance,  Tissues  belonging  to  the  Connective-Substance  Group,  Tissues  com- 
posed of  Transformed,  and,  as  a  rule,  Cohering  Cells,  with  Homogeneous,  Scanty,  and  more  or  less 
SoUd  Intermediate  Substance,  Composite  Tissues:  The  Organs  of  the  Body — Organs  of  the 
Vegetative  Type,  Organs  of  the  Animal  Group. 

FLINT. 
Manual  of  Chemical   Examination   of 

the  Urine  in  Disease.     With  Brief  Directions  for  the 
Examination  of  the  most  Common  Varieties  of  Urinary 


Calculi, 


By  AUSTIN  FLINT,  Jr.,  M.D., 


Professor  of  Physiology  and  Microscopy  in  the  BcUevuo  Hospital  Medical  College;  Fellow  of  tlje 
New  York  Academy  of  Medicine;  Member  of  the  Medical  Society  of  the  County  of  New 
York ;  llesident  Member  of  the  Lyceum  of  Natural  History  in  the  City  of  New  York,  etc. 

Third  Edition,  revised  and  corrected.    1  vol.,  12mo.    77  pp.    Cloth,  $1.00. 

The  chief  aim  of  this  little  work  is  to  enable  the  busy  practitioner  to  make  for 
himself,  rapidly  and  easily,  all  ordinary  examinations  of  Urine ;  to  give  him  the 
benefit  of  the  author's  experience  in  eliminating  little  difficulties  in  the  manipula- 
tions, and  in  reducing  processes  of  analysis  to  the  utmost  simplicity  that  is  con- 
sistent with  accuracy. 

"  We  do  not  know  of  any  work  in  English  so  complete  and  handy  as  the  Manual  now  offered 
to  the  Profession  by  Dr.  Flint,  and  the  high  scientific  reputation  of  the  author  is  a  sufBcient 
guarantee  of  the  accuracy  of  all  the  directions  given." — Journal  of  Applied  Chemistry. 

"Wo  can  unhesitatingly  recommend  this  Manual." — Psychological  Journal. 
■  ■  •••  Eminently  practical." — Detroit  lieview  Of  Medicine. 


D.  Appleton  c&   Co?s  Medical  Publications.  ') 

FLIlSrT. 

The  Physiology  of  Man.  Designed  to rep^ 
resent  the  Existing  State  of  Physiological  Scietice  as 
applied  to  the  Functions  of  the  Human  Body, 

By  AUSTIN"  FLIXT,  Jr.,  M.  D., 

Professor  of  Thyslolo^  and  Microscopy  in  the  P.cllcvue  Hospital  Jloflical  Col'.eg^Ss  nnd  in  th« 
Long-  Island  Collef^o  llospiUil;  Fellow  of  tlio  New  York  Academy  of  Medicine;  Microscopiat 
tx)  Bellevuo  lIospitaL 

Kew  and  thorouglily  revised  Edition.    In  Five  Volumes.    8vo.    Tinted  Paper. 
Volume  I. — The  Blood ;  Circulation^  Respiration. 

8vo.    502  pp.    Clotli,  84.50. 

"  If  the  remaining  portions  of  this  woi  k  arc  compiled  with  the  same  care  and 
accuracy,  the  whole  may  vie  with  any  of  those  that  have  of  late  years  been  pro- 
duced in  our  own  or  in  foreign  languages." — British  and  Foixign  Medico-Chirurgu 
cal  Revieiv. 

"  As  a  book  of  general  information  it  will  be  found  useful  to  the  practitioner, 
and,  as  a  book  of  reference,  invaluable  in  the  hands  of  the  anatomist  and  physi- 
ologist."— Dublin  Qicartcrbj  Journai  of  Medical  Science. 

"  The  complete  work  will  prove  a  valuable  addition  to  our  systematic  treatises 
on  human  physiology." — The  Lancet. 

"  To  those  who  desire  to  get  in  one  volume  a  concise  and  clear,  and  at  the 
same  time  sufficiently  full  rcsunifi  of  '  the  existing  state  of  physiological  science,' 
wc  can  heartily  recommend  Dr.  Flint's  work.  Moreover,  as  a  work  of  typographi- 
cal art  it  deserves  a  prominent  pl;\ce  upon  our  library-shelves.  Messrs.  Api)lcton 
.^  Co.  deserve  the  thanlvs  of  the  juofcssion  for  the  very  handsome  style  in  which 
they  issue  medical  works.  They  give  us  hope  of  a  time  when  it  will  be  very 
generally  believed  by  publishers  that  physicians'  eyes  are  worth  saving." — Jledi- 
en'  Gazette. 

Volume      II.  —  Alimentation  /    Digestion  ;    Absorption  / 
Z/ymph  and  Chyle. 

8vo.    556  pp.    Cloth,  S4.50. 

"  The  second  instalment  of  this  work  fulfils  all  the  expectations  raised  by  the 
perusal  of  the  fii-st.  .  .  .  The  author's  explanations  and  deductions  bear 
evidence  of  much  careful  reflection  and  study.  ...  The  entire  work  is  one 
of  rare  interest.  The  author's  style  is  as  clear  and  concise  as  his  method  iS 
studious,  careful,  and  elaborate." — Philadelj)hia  Inquirer. 

"  We  regard  the  two  treatises  already  issued  as  the  very  best  on  human  physi- 
ology which  the  English  or  any  other  language  affords,  and  we  recommend  them 
with  thorough  confidence  to  students,  practitioners,  and  laymen,  as  models  of 
literary  and  scientific  ability." — ^V.  Y.  Medical  Journal. 

"  We  have  found  the  style  easy,  lucid,  and  at  the  same  time  terse.  The  prac- 
tical and  positive  results  of  physiological  investigation  are  succinctly  statecL 
without,  it  would  seem,  extended  discussion  of  disputed  ^omis."— Boston  Medical 
and  Surgical  Journal. 

"  It  is  a  volume  which  will  be  welcome  to  the  advanced  student,  and  as  a 
work  of  reference." — The  Lancet. 

"  The  leading  subjects  treated  of  are  presented  in  distinct  parts,  each  of  which 
IS  designed  to  be  an  exhaustive  essay  on  tht-t  to  which  it  refers."—  Western  Jour, 
nal  of  Medicine. 


10  D.  Appleton  &   Co.^s  Medical  Publications. 

Flint's  Physiology.  Volume  in.— Secretion ;  Mo 
cretion/  Ductless  Glajids ;  Nutrition  j  Animal  Seat  ^ 
Movements  /    Voice  and  Speech. 

8vo.    626  pp.    Cloth,  $4.50. 

"  Dr.  Flint's  reputation  is  sufficient  to  give  a  character  to  the  book  among  the 
profession,  where  it  will  chiefly  circulate,  and  many  of  the  facts  given  have  been 
verified  by  the  author  in  his  laboratory  and  in  public  demonstration." — Chicago 
Courier. 

"  The  author  bestows  judicious  care  and  labor.  Facts  are  selected  with  dis- 
crimination, theories  critically  examined,  and  conclusions  enunciated  with  com- 
mendable clearness  and  precision." — American  Journal  of  the  Medical  Sciences. 

Yoluine  IV. — The  JVervous  System. 

8to.  Cloth,  $4.50. 

This  volume  embodies  the  results  of  exhaustive  study,  and  of  a  long  and' 
laborious  series  of  experiments,  presented  in  a  manner  remarkable  for  its  strength 
and  clearness.  No  other  department  of  physiology  has  so  profound  an  interest 
for  the  modern  and  progressive  physician  as  that  pertaining  to  the  nervous- 
system.  The  diseases  of  this  system  are  now  engaging  the  study  and  attention 
of  some  of  the  greatest  minds  in  the  medical  world,  and  in  order  to  follow  their 
brilliant  discoveries  and  developments,  especially  in  connection  with  the  science 
of  electrology,  it  is  absolutely  necessary  to  obtain  a  clear  and  settled  knowledge- 
of  the  anatomy  and  physiology  of  the  nervous  system.  It  is  the  design  of  this 
work  to  impart  that  knowledge  free  from  the  perplexing  speculations  and  uncer- 
tainties that  have  no  real  value  for  the  practical  student  of  medicine.  The 
author  boldly  tests  every  theory  for  himself,  and  asks  his  readers  to  accept  noth- 
ing that  is  not  capable  of  demonstration.  The  properties  of  the  cerebro-spinal, 
nervous,  and  sympathetic  systems  are  treated  of  in  a  manner  at  once  lucid,, 
thorough,  and  interesting. 

Although  this  volume  is  one,  perhaps  the  most  important  one,  of  the  author's* 
admirable  series  in  the  Physiology  of  Man,  it  is  nevertheless  complete  in  itself 
and  may  be  safely  pronounced  indispensable  to  every  physician  who  takes  a  pride 
and  interest  in  the  progress  of  medical  science. 

Volume  V. — Special  Senses;  Generation. 

8vo.   Cloth,  $4.50. 

"  The  present  volume  completes  the  task,  begun  eleven  years  ago,  of  preparing 
a  work,  intended  to  represent  the  existing  state  of  physiological  science,  as  ap- 
plied to  the  functions  of  the  human  body.  The  kindly  reception  which  the  first 
four  volumes  have  received  has  done  much  to  sustain  the  author  in  an  under- 
taking, the  magnitude  of  which  he  has  appreciated  more  and  more  as  the  work 
has  progressed. 

"  In  the  fifth  and  last  volume,  an  attempt  has  been  made  to  give  a  clear  account 
of  the  physiology  of  the  special  senses  and  generation,  a  most  difficult  and  delicate 
undertaking.  .  .  , 

"Finally,  as  regards  the  last,  as  well  as  the  former  volumes,  the  author  can 
only  say  that  he  has  spared  neither  time  nor  labor  in  their  preparation;  and  the 
imperfections  in  their  execution  have  been  due  to  deficiency  in  ability  and  oppor- 
tunity. He  indulges  the  hope,  however,  that  he  has  written  a  book  which  may 
assist  his  fellow-workers,  and  interest,  not  only  the  student  and  practitioner  of 
medicine,  but  some  others  who  desire  to  keep  pace  with  the  progress  of  Natural 
Science. ' ' — Eilracts  from  Preface. 


D.  Appleton  <&  Co.^s  Medical  Publications.  11 

Flint's   Text-Book   of  Human    Physi- 

ology,  for  the  Use  of  Students  and  Practitioners  of  Medi- 
cine. 

In  one  large  octavo  volume  of  978  pages,  elegantly  printed  on  fine  paper,  and 
profusely  illustrated  with  three  Lithographic  Plates  and  313  Engrav- 
ings on  Wood.     Price,  in  cloth,  $6.00 ;  sheep,  $7.00. 

While  Prof.  Flint's  "Physiology  of  Man,"  in  five  octavo  volumes,  also  published  by  D.  Apple- 
ton  &  Co.,  is  invaluable  as  a  book  of  reference,  giving  an  epitome  of  the  literature  of  physiology, 
with  copious  references  to  other  authors,  the  pubUshers  have  appreciated  the  necessity  for  a  new 
text-book,  for  the  use  of  students  and  practitioners  of  medicine. 

This  new  work  is  intended  to  meet  this  pressing  want,  and  It  contains  most  of  the  facts  pre- 
sented In  the  larger  treatise,  without  historical  references  or  discussions  of  minor  and  contro- 
verted questions.  The  high  reputation  of  the  author  as  a  public  teacher,  and  the  success  of  the 
larger  treatise,  render  it  certain  that  the  "  Text-book  "  will  be  admirably  adapted  to  the  wants  of 
medical  students. 

In  the  "  Text-book,"  all  Important  points  connected  with  Human  Physiology  are  treated  of 
ftilly  and  clearly,  and  many  subjects,  such  as  the  Nervous  System,  the  Special  Senses,  etc.,  the 
treatment  of  which  is  barren  and  unsatisfactory  in  many  works  written  or  republished  In  this 
country,  are  brought  fully  up  to  the  requirements  of  the  day. 

The  publishers  have  given  great  attention  to  the  execution  of  the  illustrations,  few  of  which 
are  familiar  to  American  readers.  It  being  almost  impossible  to  reproduce  some  of  the  cuts 
taken  from  foreign  works,  they  have  succeeded  in  obtaining  abroad  about  one  hundred  electro- 
types from  the  original  engravings  contained  in  Sappey'a  great  work  upon  Anatomy,  which  are 
unequaled  In  their  mechanical  execution.  The  subject  of  Generation  is  also  illustrated  by  litho- 
graphic plates  taken  from  Haeckel. 

The  great  care  necessary  in  the  printing  of  the  elaborata  illustrations  has  caused  an  unavoid- 
able delay  in  the  appearance  of  the  work ;  but  the  publishers  feel  confident  that  it  will  ftilly  meet 
their  expectations,  and  justify  the  reputation  of  its  author. 

"  la  preparing  this  text-book  for  the  use  of  students  and  practitioners  of  medicine,  I  have  en- 
deavored to  adapt  it  to  the  wants  of  the  profession,  as  they  have  appeared  to  me  after  a  consider- 
able experience  as  a  public  teacher  of  human  physiology.  My  large  treatise  in  five  volumes  is 
here  condensed,  and  I  have  omitted  bibliographical  citations  and  matters  of  purely  historical  In- 
terest. Many  subjects,  which  were  considered  rather  elaborately  in  my  larger  work,  are  here 
presented  in  a  much  more  concise  form.  I  have  added,  also,  numerous  illustrations,  which  I 
hope  may  lighten  the  labors  of  the  student.  A  few  of  these  are  original,  but  by  far  the  greatest 
part  has  been  selected  from  reliable  authorities.  I  have  thought  it  not  without  historical  Interest 
to  reproduce  exactly  some  of  the  classical  engravings  from  the  works  of  great  discoverers,  such 
as  illustrations  contained  in  the  original  editions  of  Fabricius,  Harvey,  and  Asellius.  In  addition, 
I  have  reproduced  a  few  of  the  beautiful  microscopical  photographs  taken  at  the  United  States 
Army  Medical  Museum,  under  the  direction  of  Dr.  J.  J.  Woodward,  to  whom  I  here  express  my 
grateful  acknowledgments.  I  have  also  to  thank  M.  Sappey  for  his  kindness  In  furnishing 
electrotypes  of  many  of  the  superb  engravings  with  which  his  great  work  upon  Anatomy  is  Illus- 
trated. 

"  My  work  in  five  volumes  was  intended  as  a  book  of  reference,  which  I  hope  will  continue  to 
be  useful  to  those  who  desire  an  account  of  the  literature  of  physiology,  as  well  as  a  statement  of 
the  facts  of  the  science.  I  have  always  endeavored,  in  public  teaching,  to  avoid  giving  undue 
prominence  to  points  in  which  I  might  myself  be  particularly  interested,  ftom  having  made  them 
subjects  of  special  study  or  of  original  research.  In  my  text-book  I  have  carried  out  the  same 
idea,  striving  to  teach,  systematically  and  with  uniform  emphasis,  what  students  of  medicine  ore 
expected  to  learn  in  physiology,  and  avoiding  elaborate  discussions  of  subjects  not  directly  con- 
oected  with  practical  medicine,  surgery,  and  obstetrics.  While  I  have  referred  to  my  original 
observations  upon  the  location  of  the  sense  of  want  of  air  in  the  general  system,  the  new  ex- 
cretory function  of  the  liver,  the  function  of  glycogenosis,  the  influence  of  muscular  e.xerclse  upon 
the  elimination  of  urea,  etc.,  I  have  not  considered  these  subjects  with  great  minuteness,  and 
have  generally  referred  the  reader  to  monographs  for  the  details  of  my  e.xperiments. 

"  Finally,  in  presenting  this  work  to  the  medical  profession,  I  cannot  refrain  from  an  expres- 
sion of  my  acknowledgments  to  the  publishers,  who  have  spared  nothing  in  carrying  out  mr 
views,  and  have  devot^  special  pains  to  the  mechanical  execution  of  the  Illustrations." — AtUhort 
Prefact. 


J2-  D.  Appleton  &  Co^s  3Iedical  Publications. 

FLINT. 
On  the  Physiological  Effects  of  Severe 

and  Protracted  Muscular  Exercise.      With  special  refer- 
ence to  its  Influence  xipon  the  Excretion  of  Nitrogen. 
By  AUSTIN  FLINT,  Jr.,  M.  D., 

Trofessor  of  Physiology  in  the  Bellevue  Hospital  Medical  College,  New  York,  etc.,  etc. 
1  vol.,  8vo.    91  pp.    Cloth,  $1.00. 

This  monograph  on  the  relations  of  Urea  to  Exercise  is  the  result  of  a  thorough  and  careful 
Investigation  made  in  the  case  of  Mr.  Edward  Payson  Weston,  the  celebrated  pedestrian.  Tlie 
chemical  analyses  were  made  under  the  direction  of  R.  O.  Doreinus,  M.  D..  Professor  of  Chemistry 
and  To.xicology  in  the  Bellevue  Hospital  Medical  College,  by  Mr.  Oscar  Locw,  his  assistant.  The 
observations  were  made  with  the  cooperation  of  J.  C.  Dalton.  M.  D  ,  Professor  of  Physiology  in 
the  College  of  Physicians  and  Surgeons;  Ale.vander  B.  Mott,  M.  D.,  Prol'essor  of  Surgical  .Vuat- 
omy;  W.  H.  Van  Buren,  M.  D.,  Profes.sor  of  Principles  of  Surgery;  Austin  Flint,  M.  D.,  Pro- 
fessor of  the  Principles  and  Practice  of  Medicine;  W.  A.  Hammond,  J[.  I).,  Professor  of  Diseases 
of  the  Mind  and  Nervous  System— all  of  the  Bellevue  Hospital  Medical  College. 

"This  work  will  be  found  interesting  to  every  physician.  A  number  of  important  results 
were  obtained  valuable  to  the  physiologist." — Cincinnati  Medical  Repertory. 

HAMILTON. 

Clinical  Electro-Therapeutics.  {Medicaiand 

ISurgical.)     A  Manual  for  Physicians  for  the  Treatment 
more  especially  of  Nervous  Piseases. 

By  ALLAN  McLANE  HAMILTON,  M.  D., 

Physician  in  charge  of  the  New  York  State  Hospital  for  Diseases  of  the  Nervous  System ;  Mem- 
ber of  the  New  York  Neurological  and  County  Medical  Societies,  etc.,  etc. 

With  Numerous  Illustrations.    1  vol.,  8vo.    Cloth.    Price,  $2.00. 

This  work  is  the  compilation  of  well-tried  measures  and  reported  cases,  and  is  intended  as  a 
simple  guide  for  the  general  practitioner.  It  is  as  free  from  confusing  theories,  technical  terms, 
and  unproved  statements,  as  possible.  Electricity  is  indorsed  as  a  very  valuable  remedy  iu  cer- 
tain diseases,  and  as  an  invaluable  therapeutical  me.ans  in  nearly  all  forms  of  Neevous  Dxsrasb; 
but  not  as  a  specific  for  every  human  ill,  mental  and  physical. 

HAMMOND. 

Insanity  in  its  Relations  to  Crime,   a 

Text  and  a  Commentary. 

By  WILLIAM   A.   HAMMOND,  M.  D. 
1  vol.,  8vo.    77  pp.    Cloth,  $1.00. 

"  A  part  of  this  essay,  under  the  title  '  Society  versus  Insanity,'  was  contributed  to  Putnam's 
Magazine,  for  September,  1S70.  The  gi-eater  portion  is  now  tirst  published.  The  importance  of 
the  subject  considered  can  scarcely  be  over-estimated,  whether  we  regard  It  from  the  stand-point 
of  science  or  social  economy;  and,  if  I  have  aided  in  its  elucidation,  my  object  will  have  been  at- 
tained."— From  Author's  Preface. 

Clinical  Lectures  on   Diseases   of  the 

Nervous    System.      Delivered  at  the   Bellevue   Hospital 
Medical  College. 

By  WILLIAM  A.  HAMMOND,  M.  D., 

Professor  of  Diseases  of  the  Mind  and  Nervous  System,  etc.    Edited,  with  Notes,  by  T.  M.  B. 
CROSS,  M.  D.,  Assistant  to  the  Chairs  of  Diseases  of  the  Mind  and  Nervous  System,  etc. 

In  one  handsome  volume  of  300  pages.    Price,  $3.50. 


D.  Appleton  &  Co.''s  Medical  Publications.  13 


HAMMOND. 
A  Treatise  on  Diseases  of  the  Nervous 

System. 

By  WILLIAM   A.   HAMMOND,  M.  D., 

Professor  of  Diseases  of  tlic  Mind  and  Nervous  System  in  the  Medical  Department  of  the  Univer- 
sity of  the  City  of  New  Tork  ;  President  of  the  New  York  Neurological  Society,  etc.,  etc. 

Sixth  Edition,     1  vol.,  8vo.     Strong  Cloth  Binding,  $6.00;    Sheep,   S7.00. 

The  remarkable  success  attendant  on  the  issue  of  the  five  previous  editions  of  this  work  in 
less  than  four  years  has  eneonrap-ed  the  author  and  publishers  to  attempt  to  make  the  work  still 
more  worthy  the  confidence  of  the  medical  profession.  A  great  part  of  the  treatise  has  boon  en- 
tirely rewritten,  and  several  new  chapters  hare  been  added.  By  a  change  in  type,  and  enliir^nng 
the  page,  the  new  matter,  amounting  to  one-half  of  the  original  work,  has  been  added  without 
increasing  materially  the  bulk  of  the  volume.  Many  new  illustrations  have  been  incorporated  in 
the  text,  and  the  whole  treatise  has  been  brought  fully  up  to  the  present  time.  In  addition  to 
the  fund  of  personal  observation  and  experience  adduced  by  Prof.  Hammond,  the  labors  of  Eng- 
lish, French,  and  German  writers  have  received  due  attention. 

Among  the  diseases  considered  in  the  present  edition,  wliich  were  not  treated  of  in  the  former 
editions,  arc :  Chronic  Verticalar  Meningitis ;  Chronic  Basilar  Meningitis;  Cervical  Pachy-Mcn- 
Ingitls;  Spinal  Paralysis  of  Adults;  Amyotrophic  Lateral  Spinal  Sclerosis;  Facial  Atrophy; 
Organic  Diseases  of  Nerves ;  Chronic  AlcohoUc  Intoxication;  Delirium  Tremens ;  E.xophthalmic 
Goitre;  and  Anapeiratic  Paralysis — paralysis  induced  by  a  frequent  repetition  of  certain  mnsfular 
actions.  Besides  which,  extensive  alterations  and  additions  have  been  made  to  the  remarks  on 
other  aCbctions — the  departments  of  Morbid  Anatomy,  Pathology,  and  Treatment,  being  espe- 
cially amplified. 

NOTICES  OF  FORMER  EDITIONS. 

"  Free  from  useless  verbiage  and  obscurity,  it  is  evidently  the  work  of  a  man  who  knows  «  hat 
he  is  writing  about,  and  knows  how  to  write  about  it." — Chicago  Medical  Jovrnal. 

"Unquestionably  the  most  complete  treatise  on  the  diseases  to  which  it  is  devoted  which  has 
yet  appeared  in  the  English  language." — London  Medical  Times  and  Gazette. 

"This  is  a  valuable  and  comprehensive  book;  it  embraces  many  topics,  and  extends  overs 
wide  sphere.  One  of  the  most  valuable  parts  of  it  relates  to  the  Diseases  of  the  Brain  ;  while  the 
remaining  portion  of  the  volume  treats  of  the  Diseases  of  tlie  Spinal  Cord,  the  Cerebro-spinal 
System,  the  Nerve-Cells,  and  the  Peripheral  Nerves."— iJri^M  Medical  Journal. 

"The  work  before  us  is  unquestionably  the  most  exhaustive  tre.itise,  on  the  diseases  to  which 
It  is  devoted,  that  has  yet  appeared  in  English.  And  its  distinctive  value  arises  from  the  fact 
that  the  work  is  no  mere  rafflciamento  of  old  observations,  but  rests  on  his  own  experience  and 
practice,  which,  as  we  have  before  observed,  have  been  very  extensive." — American  Journal  of 
Sifphilography. 

"The  author  of  this  work  has  attained  a  high  rank  among  our  brethren  across  the  Atlantic 
from  previous  labors  in  connection  with  the  disorders  of  the  nervous  system,  as  well  as  from 
various  other  contributions  to  medical  literature,  and  he  now  holds  the  official  appointments  of 
Physician  to  the  New  Tork  State  Hospital  for  the  Diseases  of  the  Nervous  System,  and  Professor 
«f  the  same  department  in  the  Bellevue  Hospital  Medical  College.  The  present  treatise  is  the 
friilt  of  the  experience  thus  acquired,  and  we  have  no  hesitation  in  pronouncing  it  a  most  valu- 
kble  addition  to  our  systematic  Uterature."— C/a^f^ow  Medical  Journal. 


14 


D.  Appleton  &    Co.'^s  Medical  Publications. 


HOFFMANlSr. 
Manual  of  Chemical  Analysis,  as  appUed 

to  the  Examination  of  Medicinal  Chemicals  and  their 
Preparations.  A  Guide  for  the  Determination  of  their 
Identity  and  Quality,  and  for  the  Detection  of  Impuri- 
ties and  Adulterations.  For  the  use  of  Pharmaceutists, 
Physicians,  Druggists,  and  Manufacturing  Chemists,  and 
Pharmaceutical  and  Medical  Students. 

Bt  FRED.  HOFFMANN,  Phil.  D. 

Oue  vol.,  8vo.    Richly  Illustrated.    Cloth.    Price,  $3. 

SPECIMEN    OF    ILLUSTRATIONS. 


This  volume  is  a  carefully -prepared  work,  and  well  up  to  the  existing  state  of  both  the  science 
fnd  art  of  modern  pharmacy.  It  is  a  book  which  will  find  its  place  in  every  medical  and  phar- 
maceutical laboratory  and  "library,  and  is  a  safe  and  instructive  gnide  to  medical  students  and 
practitioners  of  medicine."— J»n^"rica«  Journal  of  Science  and  Arts. 

In  America  this  work  has  already  met  with  general  and  unqualified  approval ;  and  in  Europe 
IS  now  beiner  welcomed  as  one  of  the  best  and  most  important  additions  to  modem  pharmsoea* 
tical  literature. 

Send  for  descriptire  circular.     Address 

D.  APPLETON  &  CO.,  549  &  551  Broadway,  N.  Y.  City. 


D.  Appleton  &   Co.^s  Medical  Publications.  15 


HOLLAND. 

Recollections  of  Past  Life, 

By  81E  HENRY  HOLLAND,  Bart,  M.  D.,  F.  R.  S.,  K  C.  B.,  etc., 
President  of  the  Royal  Inetitation  of  Great  Britain,  Physiclan-ln-Ordinary  to  the  Queen, 

etc.,  etc. 

1  vol.,  12mo,  351  pp.   Price,  Cloth,  $2.00. 

A  very  entertaining  and  instructive  narrative,  partakizig  eomewhat  of  the  nature  of 
autobiography  and  yet  distinct  from  it,  in  this,  that  its  chief  object,  as  alleged  by  the 
writer,  is  not  so  much  to  recount  the  events  of  his  own  life,  as  to  perform  the  oflBce  of 
chronicler  for  others  with  whom  he  came  in  contact  and  was  long  associated. 

The  "Life  of  Sir  Henry  Holland  "  is  one  to  be  recollected,  and  he  has  not  erred  In  gir- 
Ing  an  outline  ot  it  to  tbe  public." — Tht  Lancet. 

"  His  memory  was— is,  we  may  say,  for  he  is  still  alive  and  in  possession  of  all  his 
facalties— stored  with  recollections  of  the  most  eminent  men  and  women  of  this  cen- 
tury. ...  A  life  extendin?  over  a  period  cT  eij^hty-four  years,  and  passed  in  the  most 
active  manner,  in  the  midst  of  the  b»9t  society,  which  tlie  world  has  to  offer,  must  neces- 
sarily be  full  of  singular  interest:  and  Sir  Henry  Holland  has  fortunately  not  waited  until 
his  memory  lost  its  freshnees  before  recalling  some  of  the  incidents  in  it." — The  New 
York  Times. 


HOWE. 
Emergencies,  and  How  to  Treat  Them. 

The  Etiology,  Pathology,  and  Treatment  of  Accidents, 
Diseases,  and  Cases  of  Poisoning,  which  demand 
Prompt  Attention.  Designed  for  Students  and  Prac- 
titioners of  Medicine, 

By  JOSEPH  W.   HOWE,  M.  D., 

CUnloal  Professor  of  Surgery  in  the  Medical  Department  of  the  University  of  New  York 

Visiting  Surgeon  to  Charity  Hospital ;  Fellow  of  the  New  York  Academy 

of  Medicine,  etc.,  etc. 

1  vol.,  8vo.    Ciotii,  $3.00. 

"This  work  has  a  taking  title,  and  was  written  by  a  gentlemen  of  acknowledged  ability,  to 
fill  a  void  in  the  profession.  ...  To  the  general  practitioner  in  towns,  villages,  and  In  the 
country,  where  the  aid  and  moral  support  of  a  consultation  cannot  be  availed  of,  this  volume 
will  be  recognized  as  a  valuable  help.  We  commend  it  to  the  profession. — Cincinnati  Lancti 
and  Observer. 

"  This  work  is  certainly  novel  in  character,  and  its  usefuhiess  and  acceptabllitv  are  as  marked 
as  its  novelty.  .  .  .  The  book  is  confidently  recommended." — liichmond  and  Louisville  Med- 
ical Journal.  ,      ,  ,       ,..,,,.,  »     ^ 

"  This  volume  Is  a  practical  illustration  of  the  positive  side  of  the  physician  s  hfe,  a  constant 
remhider  of  what  he  is  to  do  in  the  sudden  emergencies  which  frequently  occur  in  practice. 
.  .  .  The  author  wastes  no  words,  but  devotes  bimsilf  to  the  description  of  each  disease  as  if 
the  patient  were  under  his  hands.  Because  it  is  a  good  book  we  recommend  it  most  heartily  t« 
the  profession."— 5o«ton  Jfedical  and  Surgical  Journal. 

"  This  work  bears  evidence  of  a  thorough  practical  acouaintance  with  the  different  branches 
of  the  profession.  ITie  author  seems  to  possess  a  peculiar  aptitude  for  imparting  Instruction 
as  well  as  for  simpUfying  tedious  details.  ...  A  careful  peru.sal  will  amply  repay  the  student 
tiadprACtit\oneT.''—S'ew  York  ^fedical  Journal."'  ^    ,   r  t  ^r  d    .i^i^^y.^1 

"This  is  the  best  work  of  the  kind  we  have  ever  seen."— Ae^c  York  Journal  of  Peydtoloffical 
Medicine. 


16  D.  Appleton  <&   Co.''s  Jledical  Publications. 

HOWE. 
The  Breath,  and  the  Diseases  which  give 

it  a  Fetid  Odor.     With  Directions  for  Treatment. 
By  JOSEPH  W.  HOWE,  M.  D., 

uthor  of  "Emerfjeccies,"  "Winter  Homes,"  etc;  Clinical  Professor  of  Surpery  in  the  Medical 
Department  of  the  University  of  New  York;  Visiting"-  Sur^reon  to  Charity  and  St.  Francis 
Hospitals;  Fellow  of  the  New  York  Academy  of  Mcdieiue,  etc. 

"It  is  somewhat  remarkable  that  the  subject  of  fetid  breath,  which  occasions  so  much  annoy- 
ance. .  .  .  should  )iave  attracted  so  little  attention  from  authors  and  investigators.  Hence  a 
thorougrhly  scicnlitic  exposition  of  the  whole  subject,  such  as  Dr.  Howe  h.as  piven  us,  has  long 
been  a  desideratum.  .  .  .  Tins  Uttle  volume  well  deserves  the  attention  of  physicians,  to  whom 
we  commend  it  most  hitrhly." — Chicago  Medical  Journal. 

" .  .  .  To  any  one  sulTeiinp  from  the  affection,  either  in  his  own  person  or  in  th.it  of  his  inti- 
mate acquaintances,  we  can  commend  this  volume  as  containing  all  thai  is  known  concerning  the 
suliject,  set  forth  in  a  pleasant  style." — Philaddphia  Medical  Times. 

'■  This  little  work  is  on  a  subject  that  has  heretofore  been  almost  entirely  ignored  by  medical 
authors,  yet  its  importance  is  well  known  by  every  practitioner.  .  .  .  Tlie  author  gives  a  succinct 
account  of  the  diseased  conditions  in  which  a  fetid  bre.ith  is  an  impi)rtnnt  symjitom,  witli  his 
method  of  treatment.  We  consider  the  work  a  real  addition  to  medical  literatui-e." — Cincinnati 
Medical  Journal. 

HUXLEY  AND   YOUMANS. 
The  Elements  of  Physiology  and  Wy- 

giene.     With  Numerous  Illustrations. 

ByTUOMAS  II.  HUXLEY,  LL.  D.,  F.R.S.,  and 

WILLIAM  JAY  YOUMANS,  M.  D. 

New  and  Revised  Edition.    1  vol.,  12mo.    420  pp.    SI. 75. 

A  text-book  for  educational  institutions,  and  a  valuable  elementary  work  for  students  of  medi- 
cine. The  greater  jiortion  is  from  the  pen  of  Professor  HiLxley,  adajjtod  by  Dr.  Youmans  to  the 
circumstances  and  requirements  of  American  education.  The  eminent  claim  of  Professor  IIux- 
ley"s  "Elementary  Physiology"  is,  that,  while  up  to  the  times,  it  is  trustworthy  in  its  presenta- 
ti"U  of  the  subject;  while  rejecting  discredited  doctrines  and  doubtful  speculations,  it  embodies 
the  latest  results  that  are  established,  and  represents  the  itresent  actual  state  of  physiological 
knowledge. 

•'A  valuable  contribution  to  anatomical  and  physiolor;ical  science." — Religious  Telescope. 

"  A  clear  and  well  arranged  work,  embracing  the  latest  discoveries  and  accei)ted  theories." — 
Buffalo  Commercial. 

"Teeming  with  information  concerning  the  human  physical  economy." — Evening  Journal. 

HUXLEY. 
The  Anatomy  of  Vertebrated  Animals. 

By  THOMAS  HENRY  HUXLEY,  LL.D.,  F.  R.  S., 

Author  of  "  Man's  Place  in  Nature,"  '■  On  the  Origin  of  Species,"  "  Lay  Sermons  and  Addresses,** 

etc. 

1  vol.,  12mo.   Cloth,  $2.50. 

The  former  works  of  Prof  Hu.tley  leave  no  room  for  doubt  as  to  the  importance  and  value  of 
his  new  volume.  It  is  one  which  will  be  very  acceptable  to  all  who  are  interested  in  the  subject 
of  which  it  treats. 

"This  long-expected  work  will  be  cordially  welcomed  by  all  students  and  teachers  of  Com- 
parative Anatomy  as  a  compendious,  reliable,  and,  notwithstanding  its  small  dimensions,  most 
comiirehensive  guide  on  the  subject  of  which  it  treats.  To  praise  or  to  criticise  the  work  of  so 
accomplished  a  master  of  his  favorite  science  would  bo  equally  out  of  place.  It  is  enough  to  say 
that  it  realizes,  in  a  rem.arkable  degree,  the  anticipations  which  have  been  formed  of  it;  and  that 
It  presents  an  extraordinary  combination  of  wide,  general  news,  with  the  clear,  accurate,  and 
Bucninct  statement  of  a  prodigious  number  of  individual  facts." — Xainre. 


D.  Appleton  <S>   Co.^s  Medical  Publicatiojis.  17 


JOHNSON. 
The    Chemistry    of    Common     Life. 

Illustrated  with  numerous  Wood  Engravings. 
By  JAMES  F.  JOHNSON,  M.  A.,  F.  R.  S.,  F.  G.  S.,  etc.,  etc., 

Author  of  "Lectvires  on  Agricultural  Chemistry  and  Geology,"  "A  Catechism  of  Agricultural 
Chemistry  and  Geology,"  etc. 

2  vols.,  12)110.    Cloth,  $3.00. 

It  has  been  the  object  of  tlie  author  in  this  work  to  exliibit  the 

present  condition   of   chemical   knowledge,    and   of  matured  scientific 

opinion,  upon  the  subjects  to  which  it  is  devoted.     The  reader  will  not 

ho  surprised,  therefore,  should  he  find  in  it  some  things  which  differ 

from  what  is  to  be  found  in  other  popular  works  already  in  his  hands  or 

on  the  shelves  of  his  library. 

LETTERMAN. 
Medical  Recollections  of  the  Army  of 

the  Potomac. 

By  JONATHAN  LETTERMAN,  M.  D., 

Late  Surgeon  U.  8.  A.,  and  Umiical  Director  of  the  Ai-my  of  the  Potomac. 
1  vol.,  8vo.    134  pp.    Cloth,  Sl.OO. 
"  This  accouut  of  the  medical  department  of  the  Army  of  the  Poto- 
mac has  been  prepared,  amid  pressing  engagements,   in  the  hope   that 
the  labors  of  the  medical  officers  of  that  army  may  be  known  to  an  in- 
telligent people,  with  whom  to  know  is  to  appreciate;  and  as  an  affeo 
tionate  tribute  to  many,  long  my  zealous  and  efficient  colleagues,  who, 
in  days  of  trial  and  danger,  which  have  passed,  let  us  hope  never  to  re- 
turn, evinced  their  devotion  to  their  country  and  to  the  cause  of  hu- 
manity, without  hope  of  promotion  or  expectation  of  reward." — Preface. 

"  We  venture  to  assert  that  but  few  who  open  this  volume  of  medical  annala, 
pregnant  as  they  are  with  instruction,  will  care  to  do  otherwise  than  finish  them 
at  a  sitting." — Medical  Record. 

"  A  graceful  and  afiFectionate  tribute." — N.  Y.  Medical  Journal. 

LEWES. 

The  Physiology  of  Common  Life. 

By  GEORGE  HENRY  LEWES, 

Author  of  "Seaside  Studies,"  "Life  of  Goethe,"  etc. 

2  volt.,  12mo.     Cloth,  $3.00. 
The  object  of  this  work  differs  from  that  of  all  others  on  popular 
flcience  in  its  attempt  to  meet  the  wants  of  the  student,  while  meeting 
those  of  the  general  reader,  who  is  supposed  to  be  wholly  unacquainted 
with  anatomy  and  physiology. 


18  D.  Appleion  <t  CoJ's  Medical  Publications. 

MAUDSLEY. 
The  Physiology  and  Pathology  of  the 

Mind. 

By  henry  MAUDSLEY,  M.  D.,  London, 
Fellow  of  the  Eoyal  College  of  Physicians ;  Professor  of  Medical  Jurisprudence  In  University  Col- 
lege, London;  President-elect  of  the  Medico-Psychological  Association;  Honorary  Member  of 
the  Medico-Psychological  Society  of  Paris,  of  the  Imperial  Society  of  Physicians  of  Vienna, 
and  of  the  Society  for  the  Promotion  of  Psychiatry  and  i'orensic  Psychology  of  Vienna; 
formerly  Eesident  Physician  of  the  Manchester  Royal  Lunatic  Asylum,  etc.,  etc. 

1  VOL,  8vo.    422  pp.    Cloth,  $3.00. 

This  work  aims,  in  the  first  place,  to  treat  of  mental  phenomena  from  a 
physiological  rather  than  from  a  metaphysical  point  of  view ;  and,  secondly,  to 
bring  the  manifold  instructive  instances  presented  by  the  unsound  mind  to  bear 
upon  the  interpretation  of  the  obscure  problems  of  mental  science. 

"  Dr.  Maudsley  has  had  the  courage  to  undertake,  and  the  skill  to  execute,  what  is,  at  least  in 
English,  an  original  enterprise."— Xo/irfon  Saturday  Review. 

"  It  is  BO  full  of  sensible  reflections  and  sound  truths  that  their  wide  dissemination  could  not 
but  be  of  benefit  to  all  thinking  peTSonsy— Psychological  Journal. 

"  Unquestionably  one  of  the  ablest  and  most  important  works  on  the  subject  of  which  it 
treats  tliat  has  ever  appeared,  and  does  credit  to  his  pliilosophical  acumen  and  accurate  observa- 
tion."—J/edica/  liecord. 

"  We  lay  down  the  book  with  admiration,  and  we  commend  it  most  earnestly  to  our  readers 
as  a  work  of  extraordinary  merit  and  originality — one  of  those  productions  that  are  evolved  only 
occasionally  in  the  lapse  of  years,  and  that  serve  to  mark  actual  and  very  decided  advantages  in 
knowledge  and  science." — N.  T.  Medical  Journal. 

Body  and  Mind  :  An  inquiry  into  their  Conr 
nection  and  Mutual  Influence,  especially  in  reference  to 
Mental  Disorders ;  an  enlarged  and  revised  edition  to 
which  are  added  Psychological  Essays. 

By  henry   MAUDSLEY,  M.  D.,  London, 
Author  of  "  The  Physiology  and  Pathology  of  the  Mind." 

1  vol.,  12mo.    155  pp.    Cloth,  $1.00. 

The  general  plan  of  this  work  may  be  described  as  being  to  bring  man,  both 
in  his  physical  and  mental  relations,  as  much  as  possible  within  the  scope  of  sci- 
entific inquiry. 

"  A  representative  work,  which  every  one  must  study  who  desires  to  know  what  Is  doing  In  th* 
way  of  real  progress,  and  not  mere  chatter,  about  mental  physiology  and  pathology." — Lancet. 
"  It  distinctly  marks  a  step  in  the  progress  of  scientific  psychology." —  The  Practitioner. 

Responsibility  in  Mental  Diseases. 

By  henry  MAUDSLEY,  M.  D.,  London, 
Author  of  "  Body  and  Mind,"  "  Physiology  and  Pathology  of  the  Mind." 

1  vol.,  12mo.    313  pp.    Cloth,  $1.50. 

"  This  book  Is  a  compact  presentation  of  those  facts  and  principles  which  require  to  be  taken 
Into  account  in  estimating  human  responsibility — not  legal  responsibility  merely,  but  responsi- 
bility for  conduct  in  the  family,  the  school,  and  all  phases  of  social  relation  in  which  obligation 
enters  as  an  element.  The  work  is  new  in  plan,  and  was  written  to  supply  a  wide-felt  want 
wlUch  has  not  hitherto  been  met." — The  Pojmlar  Science  Monthly. 


D.  Appleton  <b   Co.'' a  Medical  Fublicatiom. 


19 


MEYER. 
Electricity  in  its  Relations  to  Practical 

Medicine. 

B7  Db.   MORITZ  MEYER, 

Boyal  Counsellor  of  Health,  eto. 

Translated  from  the  Third  German  Edition,  with  Notes  and  Additions, 
A  New  and  Kevised  Edition, 

By  WILLIAM  A.  HAMMOND,  M.  D., 

Professor  of  Diseases  of  the  Mind  and  Nervous  System,  and  of  Clinical  Medicine,  In  the  BeUevnt 
Hospital  Medical  College;  Vice-President  of  the  Academy  of  Mental  Sciences  Natioiial 
Institute  of  Letters,  Arts,  and  Sciences;  late  Surgeon-Genera  U.  8.  A,,  etc. 

1  vol.,  8vo.  497  pp.  Cloth,  $4.50. 
"  It  is  the  duty  of  every  physician  to  study  the  action  of  electricity, 
to  become  acquainted  with  its  value  in  therapeutics,  and  to  follow  the 
improvements  that  are  being  made  in  the  apparatus  for  its  application  in 
medicine,  that  he  may  be  able  to  choose  the  one  best  adapted  to  the 
treatment  of  individual  cases,  and  to  test  a  remedy  fairly  and  withont 
prejudice,  which  already,  especially  in  nervous  diseases,  has  been  used 
with  the  best  results,  and  which  promises  to  yield  an  abundant  harrort 
in  a  still  broader  domain." — From  Author's  Preface. 

BPaCDCKN   OF  nXnSTBATIONS. 


Baxton-EttfaighaaBen  Apparatoi. 

"  Those  who  do  not  read  German  are  under  great  obligations  to  WnHtm  A. 
Hammond,  who  has  given  them  not  only  an  excellent  translation  of  a  most^  ex* 
cellent  work,  but  has  given  us  much  valuable  information  and  many  suggestion* 
from  his  own  personal  experience." — Medical  Record. 

"  Dr.  Moritz  Meyer,  of  Berlin,  has  been  for  more  than  twenty  years  a  laborious 
and  conscientious  student  of  the  application  of  electricity  to  practical  medicine, 
and  the  results  of  his  labors  are  given  in  this  volume.  Dr.  Hammond,  in  making 
a  translation  of  the  third  German  edition,  has  done  a  real  service  to  the  profession 
of  this  country  and  of  Great  Britain.  Plainly  and  concisely  written,  and  simply 
and  clearly  arranged,  it  contains  just  what  the  physician  wants  to  know  on  the 
•nbject." — N.  Y.  Medical  Journal. 

"  It  is  destined  to  fill  a  want  long  felt  by  phyiicians  in  this  country." — Jo^tmcA 
of  Obstetrics 


20  D.  Appleton  cb  Go.'^s  Medical  Publications. 

MAKKOE. 
A  Treatise  on  Diseases  of  the  Bones. 

By  THOMAS  M.  MARKOE,  M.  D., 

Professor  of  Surgery  in  the  College  of  Physicians  and  Surgeons,  New  York,  etc 

■n'lxn    NUMEPvOUS    illusteations. 

1  vol.,  8vo.    Cloth,  S4.50. 

This  valuable  work  is  a  treatise  on  Diseases  of  the  Bones,  embracing  their 
structural  changes  as  affected  by  disease,  their  clinical  history  and  treatment,  in- 
cluding also  an  account  of  the  various  tumors  which  grow  in  or  upon  them.  None 
of  the  injuries  of  bone  are  included  in  its  scope,  and  no  joi7tt  diseases,  excepting 
where  the  condition  of  the  bone  is  a  prime  factor  in  the  problem  of  disease.  As 
the  work  of  an  eminent  surgeon  of  large  and  varied  experience,  it  may  be  re- 
garded as  the  best  on  the  subject,  and  a  valuable  contribution  to  medical  litera- 
ture. 

"The  book  which  I  now  offer  to  my  professional  brethren  contains  the  substance  of  the  lec- 
tures which  I  have  delivered  during  the  past  t'velve  years  at  the  college.  ...  I  have  followed 
the  leadings  of  my  own  studies  and  observations,  dwelling  more  on  those  branches  where  I  had 
seen  and  studied  most,  and  perhaps  too  much  neglecting  others  where  my  own  experience  was 
more  barren,  and  therefore  to  me  less  interesting.  I  have  endeavored,  however,  to  make  np  the 
deficiencies  of  my  own  knowledge  by  the  free  use  of  the  materials  scattered  so  richly  through 
our  periodical  literature,  which  scattered  leaves  it  is  the  right  and  the  duty  of  the  systematic 
writer  to  collect  and  to  embody  in  any  account  he  m;iy  offer  of  the  state  of  a  science  at  any  given 
penod."— Extract  from  Author''s  Preface. 

NEFTEL. 

GalvanO- Therapeutics.      The  Physiological   and 

Thera2yei(tical  Action    of   the    Galvanic    Current    vpon 

the   Acoustic,    Optic,   Sympathetic,   and  Pneumogastric 

Nerves. 

By  WILLIAM  B.  NEFTEL. 

1  vol.,  12mo.    161  pp.    Cloth,  $1.50. 

This  book  has  been  republished  at  the  request  of  several  aural  surgeons  anil 
other  professional  gentlemen,  and  is  a  valuable  treatise  on  the  subjects  of  which 
it  treats.  Its  author,  formerly  visiting  physician  to  the  largest  hospital  of  St. 
Petersburg,  has  had  the  very  best  facilities  for  investigation. 

"  This  little  work  shows,  as  far  as  it  goes,  full  knowledge  of  what  has  been 
done  on  the  subjects  treated  of,  and  the  author's  practical  acquaintance  with 
them." — New  York  Medical  Journal. 

"  Those  who  use  electricity  should  get  this  work,  and  those  who  do  not 
should  peruse  it  to  learn  that  there  is  one  more  therapeutical  agent  that  they 
could  and  should  possess." — The  Medical  Investigator. 


U.  Appleton  <&   Co.^s  JJedical  Publicatiom.  H 


NIEMEYER 
A  Text-Book  of   Practical    Medicine, 

With  Particular  Reference  to  Phijsiology  and  Patho' 
logical  Anatomy. 

By  the  late  Dr.  FELIX  VON  NIEMEYER, 

Professor  of  Pathology  and  Therapeutics;  Director  of  the  Medical  Clinic  of  the  University  of 

Tubingen. 

Translated  from  the  Eighth  German  Edition,  by  special  permission  of 

the  Authoi-, 

By  GEORGE   H.   nUMPIIREYS,   M.  D., 

lAtA  )ne  of  the  Physicians  to  the  Bureau  of  Medical  and  Suri,'ical  Relief  at  Bcllevue  Hospital  ft* 
the  Oat-door  Poor ;  Fellow  of  the  New  York  Academy  of  Medicine,  etc., 

and 

CHARLES  E.   HACKLEY,  M.  D., 

One  of  the  Physicians  to  the  New  York  Hospital;  one  of  the  Surgeons  to  the  New  York  Ey# 
and  Ear  Inliruiary ;  Fellow  of  the  Now  York  Academy  of  Medicine,  etc. 

Revised  Edition.    2  vols.,  8vo.    1,528  pp.    Cloth,  $9.00 ;  Sheep,  $11.00. 

The  author  undertakes,  first,  to  give  a  picture  of  disease  which  shall 
be  as  lifelike  and  faitlifiil  to  nature  as  possible,  instead  of  being  a  mere 
theoretical  scheme;  secondly,  so  to  utilize  the  more  recent  advances 
of  pathological  anatomy,  physiology,  and  physiological  chemistry,  as  to 
furnish  a  clearer  insight  into  the  various  processes  of  disease. 

The  work  has  met  with  the  most  flattering  reception  and  deserved 
success;  has  been  adopted  as  a  text-book  in  many  of  the  medical  colleges 
both  in  this  country  and  in  Europe;  and  has  received  the  very  highest 
encomiums  from  the  medical  and  secular  press. 

"  It  is  comprehensive  and  concise,  and  is  characterized  by  clearness  and 
originality." — Dnhlin  Quarterly  Journal  of  Jfeilicine. 

"  Its  author  is  learned  in  medical  literature ;  he  has  arranged  his  material* 
with  care  and  judgment,  and  has  thought  over  them." — 77ie  Lancet. 

"  As  a  full,  systematic,  and  thoroughly  practical  guide  for  the  student  and 
physician,  it  is  not  excelled  by  any  similar  treatise  in  any  language." — Appletcms^ 
Journal. 

"  The  author  is  an  accomplished  pathologist  and  practical  physician  ;  he  is  not 
only  capable  of  appreciating  the  new  discoveries,  which  during  the  last  ten  years 
have  been  unusually  numerous  and  important  in  scientidc  and  practical  medicine^ 
but,  by  his  clinical  experience,  he  can  put  these  new  views  to  a  practical  test,  and 
give  judgment  regarding  them." — Edinhurcih  Medical  Journal. 

"  From  its  general  excellence,  we  are  disposed  to  think  that  it  will  soon  take 
its  place  among  the  recognized  text-books." — American  Quarterly  Journal  of 
Medical  Sciences. 

"  The  first  inquiry  in  this  country  regarding  a  German  book  generally  is,  '  l» 
it  a  work  of  practical  value?  "  Without  stopping  to  consider  the  justness  of  the 
American  idea  of  the  ' practical,'  we  can  unhesitatingly  answer,  '  It  is  I'  " — A^eit 
York  Medical  Journal. 

"  The  author  has  the  power  of  sifting  the  tares  from  the  wheat — a  matter  of 
the  greatest  importance  in  a  text-book  for  students." — British  Medical  Journal. 

"  Whatever  exalted  opinion  our  countrymen  may  have  of  the  author's  talent* 
of  observation  and  his  practical  good  sense,  his  text-book  will  not  disappoint 
them,  while  those  who  are  so  unfortunate  as  to  know  him  only  by  name,  have  10 
ftore  a  rich  treat." — New  York  MeJictd  Record 


22  D.  Appleton  cfe  Co.^s  Jfedical  JPuhUcations. 

NIGHTINQALE. 

Notes    on    Nursing:    what  U  is,  and  what  U  is  not. 

By  FLORENCE  NIGHTINGALE. 

1   vol.,   12mo.     140  pp.     Cloth,  75  cents. 

Every-day  sanitary  knowledge,  or  the  knowledge  of  nursing,  or,  in  other 
words,  of  how  to  put  the  constitution  in  such  a  state  as  that  it  will  have  no  dis- 
ease or  that  it  can  recover  from  disease,  takes  a  higher  place.  It  is  recogni2ed 
as  the  knowledge  which  every  one  ought  to  have — distinct  from  medical  knowl- 
edge,  which  only  a  profession  can  have. 

NEUMANN. 
Hand-Book  of  Skin  Diseases. 

By  Dr.  ISIDOR  NEUMANN, 
Lecturer  on  Skin  Diseases  in  the  Royal  University  of  Vienna. 

rranslated  from  advanced  sheets  of  the  second  edition,  furnished  by  the 
Anther;  with  Ifotes, 

By  LUCIUS  D.  BULKLEY,  A.  M.,  M.  D., 

fkorgeonto  the  New  York  Dispensary,  Department  of  Venereal  and  Skin  Diseases;  AsBiat- 
ant  to  the  Skin  Clinic  of  the  College  of  Physicians  and  Surgeons,  New  York;  Mem- 
ber of  the  New  York  Dermatological  Society,  etc.,  etc. 

1  Tol.,  8to.   Abaut  450  pages  and  66  Woodcnts.    Cloth,  $4.00. 

Prof.  Neumann  ranks  second  only  to  Hebra,  whose  assistant  he  was  for  many  year* 
*nd  his  work  may  be  considered  as  a  fair  exponent  of  the  German  practice  of  Dermatolo 
gy.  The  book  is  abundantly  illustrated  with  plates  of  the  histology  and  pathology  of  the 
akin.  The  translator  has  endeavored,  by  means  of  notes  from  French,  English,  and  Ameri- 
can sources,  to  make  the  work  valuable  to  the  student  as  well  as  to  the  practitioner. 

"  It  is  a  work  which  I  shall  heartily  recommend  to  my  class  of  students  at  the  Univer- 
sity of  Pennsvlvania,  and  one  which  I  feel  sure  will  do  much  toward  enlightening  the  pr<^ 
fession  on  this  subject." — LouU  A.  Duhring. 

"I  know  it  to  be  a  good  book,  and  I  am  sure  that  it  is  well  translated;  and  it  is  Inter- 
esting to  find  it  illustrated  by  references  to  the  views  of  co-laborers  in  the  same  field."— 
Erasmus  Wilson. 

"  So  complete  as  to  render  it  a  most  useful  book  of  reference." — T.  McCaU  Anderson. 

"There  certainly  is  no  work  extant  which  deals  so  thoroughly  with  the  Pathological 
Anatomy  of  the  Skin  as  does  this  hand-book."— iV.  Y.  Medical  Record. 

"The  original  notes  by  Dr.  Bulkley  are  very  practical,  and  are  an  important  adjunct  to 
the  text.    .    .    .    I  anticipate  for  it  a  wide  circulation. "—iSi/cM  Z>urA:««,  io»tort. 

"  I  have  already  twice  expressed  my  favorable  opinion  of  the  book  In  print,  and  am 
glad  that  it  is  given  to  the  public  at  last." — James  C.  White,  Boston. 

"More  than  two  years  ago  we  noticed  Dr.  Neumann's  admirable  work  in  Its  originAl 
fbape ;  and  we  are  therefore  absolved  from  the  necessity  of  saying  more  than  to  repeat 
oar  strong  recommendation  of  it  to  English  readers." — Practitioner. 


o 


D.  Appleton  <&  Co.^s  Medical  Publicatiofis.  28 

PAG-ET. 
Clinical  Lectures  and  Essays. 

By  Sir  JAMES  PAGET,  Bart., 
F.  R.  8.,  D.  0.  L.,  Oxon.,  LL.  T).,  Cantab. ;   Sergeant-Surgeon  Extraordinary  to  her  Majesty  th# 
Queen;  Surgeon  to  H.  K.  H.  the  Prince  of  Wales;  Consulting  Surgeon  to  St.  Bartholomew'* 
HospitiU. 

Edited  by  HOWARD   MARSH, 
Assietant  Surgeon  to  St  Bartholomew's  Hospital,  and  to  the  Hospital  for  Sick  Childreo, 

1  vol.,  8to.    Cloth.    Price,  $5.00. 

CONTENTS. 
Thk  Various  Risks  op  Operations — Thk  Calamities  of  Surgery — Staji- 

MERINO   TVITH   OTHER   ORGANS   THAN    THOSE   OF   SPEECH — CaSES   THAT    B0NE-SkTTER3 

CURE — Strangulated  Hernia — Chronic  Pyaemia — Nervous  Mimicry — Treat- 
ment OF  Carbuncle — Sexual  Hypochondriasis — Gouty  Phlebitis — Residual 
Abscess — Dissection-Poisons — Quiet  Necrosis — Senile  Scrofula — Scarlet  Pe- 
ter after  Operations — ^Notes  for  the  Study  of  some  Constitutional  Disease* 
—Notes — Index. 

PEASLEE. 

Varian     1  UmorS  J    Their  Fathology,  Diagnosis,  and 

Treatment,  with  Reference  especially  to  Ovariotomy, 

By  E.  R.  PEASLEE,  M.D., 
Professor  of  Diseases  of  Women  in  Dartmouth  College ;  one  of  the  Consulting  Physicans  to  the 
New  York  State  Woman's  Hospital;   formerly  Professor  of  Obstetrics  and  Diseases  of 
Women  in  the  New  York  Medical  College;    Corresponding  Member  of  the  Obstetrical 
Society  of  Berlin,  etc. 

1  vol.,  8vo.   Illustrated  with  many  Woodcuts,  and  a  Steel  Engraving  of  Dr.  E. 
McDowell,  the  "  Father  of  Ovariotomy."    Price,  Cloth,  $5.00. 

This  valuable  work,  embracing  the  results  of  many  years  of  successful  experience  in  the  de- 
partment of  which  it  treats,  will  prove  most  acceptable  to  the  entire  profession ;  wliile  the  high 
Standing  of  the  author  and  his  knowledge  of  the  subject  combine  to  make  the  book  the  best  in 
the  language.  It  is  divided  into  two  parts :  the  first  treating  of  Ovarian  Tumors,  their  anatomy, 
pathology,  diagnosis,  and  treatment,  except  by  extirpation  ;  the  second  of  Ovariotomy,  its  history 
and  statistics,  and  of  the  operation.  Fully  illustrated,  and  abounding  with  information,  the  result 
of  a  prolonged  study  of  the  subject,  tlie  work  should  be  in  the  hands  of  every  physician  in  th» 
country. 

The  following  are  some  of  the  opinions  of  the  press,  at  home  and  abroad,  of  this  great  work, 
which  has  been  justly  styled,  by  an  eminent  critic,  "  the  most  complete  medical  monograph  on  a 
practical  subject  ever  produced  in  this  country." 

"His  opinions  upon  what  others  have  advised  are  clearly  set  forth,  and  are  as  Interesting  and 
Important  as  are  the  propositions  he  has  himself  to  advance;  while.there  are  a  freshness,  a  vigor, 
an  authority  about  his  writing,  which  great  practical  knowledge  alone  can  confer."' — The  Lancet. 

"Both  Wells's  and  Peaslee's  works  will  be  received  with  the  respect  due  to  the  great  repu- 
tation and  skill  of  their  authors.  Botli  exist  not  only  as  masters  o(^  their  art,  but  as  clear  and 
graceful  writers.  In  either  work  the  student  and  practitioner  will  find  the  fruits  of  rich  expe- 
rience, of  earnest  thought,  and  of  steady,  well-balanced  judgment.  Aa  England  is  proud  of 
Wells,  80  may  America  well  be  proud  of  Peaslee,  and  the  great  world  of  science  may  be  proud 
QtXioth"— British  Medical  Journal. 

"  This  is  an  excellent  work,  and  does  great  credit  to  the  industry,  ability,  science,  and  learning 
of  Dr.  Peaslee.  Few  works  issue  from  the  medical  press  so  complete,  so  exhaustively  learned, 
Bo  imbued  with  a  practical  tone,  without  losing  other  substantial  good  qualities."— jSyinAur^A 
Medical  Journal. 

"  In  closing  our  review  of  this  work,  we  cannot  avoid  again  expressing  our  appreciation  of 
the  thorough  study,  the  careful  and  honest  statements,  and  candid  spirit,  which  cliaracterize  it. 
For  the  use  of  the  student  we  should  give  the  preference  to  Dr.  Feaslee's  work,  not  only  from 
its  completeness,  but  from  its  more  methodical  arrangement."— American  Journal  of  Medical 
Sciences. 


24  D.  Appleton  &   Go.^s  Medical  Publications. 


PEREIRA. 

Dr.    Pereira's     Elements    of    Materia 

Medica  and  Therapeutics.  Abridged  and  adapted  for 
the  Use  of  3fedical  and  Pharmaceutical  Practitioners 
and  Students,  and  comprising  all  the  Medicines  of  the 
British  Pharmacopoeia,  with  such  others  as  are  frequently 
ordered  in  Prescriptions,  or  required  by  the  Physician. 

Edited  bt  ROBERT  BENTLEY  and  THEOPHILUS  REDWOOD. 

ITew  Edition.    Brought  down  to  1872.    1  vol.,  Royal  8vo.    Cloth,  $7.00  ;  Sheep, 

$8.00. 

XvCpOrtS.      Bellevue   and   Charity  Hospital  Reports  for 
1870,  containing  Valuable  Contributions  from 

{6AA.a  E.  Tatloe.  M.  D.,  Austin  Flint,  M.  D.,  Le-sos  A.  Saybe,  M.  D.,  "William  A.  IlAJki- 
MONO,  M.  D.,  T.  Gaillard  Thomas,  M.  D.,  Frank  H.  Hamilton,  M.  D.,  and  others, 

1  vol.,  Svo.    Cloth,  84.00. 

"These  institutions  are  the  most  important,  as  reg'ards  accommodations  for  pationts  and 
■variety  of  cases  treated,  of  any  on  this  continent,  and  are  surpassed  by  but  few  in  the  world. 
■The  gentlemen  conaeftod  with  them  are  acknowled;?ed  to  be  among  the  tirst  in  their  profession, 
and  the  volume  is  an  important  addition  to  the  professional  hterature  ot  this  count  y.^—Pei/cTu)- 
iogioal  Journal. 

KICHAKDSOK 
Diseases  of  Modern   Life. 

By   Dr.    B.    W.    RICHARDSON,   F.  R.  S. 
1  vol.,  12nio.    S2.00. 
,    Paet  the  FntsT.— phenomena  OF  DISEASE,  INCIDENTAL  AND  GENERAL. 
Chap.  I. — Natural  Life  to  Natural  Death.    Euthanasia. 

'■  II. — Phenomena  of  Disease,  Classification  and  Distribution. 

'■  III. — Disease  Antecedent  to  15irth. 

"  IV. — External  Origins  and  Causes  of  Disease. 

'■  V. — Phenomena  of  Disease,  fiom  Causes  External  and  Uncontrollable. 

"  VI. — Phenomena  of  Disease,  from  Causes  External  .and  Communicable. 

'■  VII. — PhenT)mena  of  Disease,  incidental  to  Old  Age  and  Natural  Decay. 

Part  the  Second.— PHENOMENA  OF  DISEASE,  INDUCED  AND  SPECIAL. 

Chap.  I. — Definition  and  Classification  of  Induced  Diseases. 

"  II. — Disease  from  Worry  and  Mental  t- train  (Broken  Heart). 

"  III. — Disease  from  "Worry  and  Mental  Strain,  continued  (Paralysis). 

"  IV. — Disease  from  Physical  Strain. 

"  V. — Disease  from  Combined  Physical  and  Mental  Strain. 

"  VI. — Disease  from  the  Influence  of  the  Passions. 

^'  VII.— Disease  from  Alcohol.     Physiological  Proem. 

•"  VIII. — Phenomena  of  Disease  froiii  Alcohol.    The  Functional  Type. 

"  IX. — Organic  Disease  from  Alcohol 

■"  X. — Disease  from  Tobacco.    Physiological  Phenomena. 

■"  XI. — Disease  from  Tobacco,  continued  (of  the  Heart  and  Lungs). 

■"  XII. — Disease  from  Tobacco,  continued  (of  the  Brain  and  Nervous  System). 

•"  XIII. — Disease  from  the  Use  of  Narcotics  (from  Opium,  Chloral,  and  Absiflthe). 

■"  XIV. — Disease  fi-om  Misuse  of  Foods. 

"  XV. — Disease  incident  to  some  Occupations. 

"  XVI.— Disease  from  Late  Hours  and  Deficient  Sleep. 

"  XVII. — Disease  from  Imperfect  Supply  of  Air. 

*     XVIII. — Disease  from  Imitation  and  Moral  Contagion. 

Part  the  Thtbd.— SUMMARY  OF  PRACTICAL  APPLICATIONS. 


D.  Appleton  &  Co.''s  Medical  Publications.  26 

SAYRE. 
Lectures  on  Orthopedic  Surgery,  and 

Diseases  of  the  Joints.     Delivered  at  Dellevue  IIos}}ital 
Medical  College  during  the  Winter  Session  of  1874-1875, 

By  lewis  a.  SAYRE,  M.  D., 

Professor  of  Orthopedic  Surgery,  Fractures  and  Dislocations,  and  Clinical  Surgery,  In  Bellevnc 
Hospital  Medical  College;  Surgeon  to  Bcllevuo  Hospital;  Consulting  Surgeon  to  Charity 
Hospital;  Consulting  Surgeon  to  St.  Elizabeth's  Hospital;  Consulting  Surgeon  to  North- 
western Dispensaiy;  Member  of  the  American  Medical  Association;  Permanent  Member 
of  the  New  York  State  Medical  Society;  Fellow  of  the  New  York  Academy  of  Medicine ; 
Member  of  the  New  York  County  Medical  Society,  of  the  New  York  Pathological  Society, 
of  the  Society  of  Neurology,  of  the  Medico-Legal  Society;  Honorary  Member  of  the  New 
Brunswick  Medical  Society;  Honorary  Member  of  the  Medical  Society  of  Norway;  Knight 
of  the  Order  of  Wasa,  by  His  Majesty  the  King  of  Sweden,  etc.,  etc. 

Illustrated  by  Numerous  Wood-Engravings.    1  vol.,  8vo.    Cloth,  tS.OO;  Sheep, 

S6.0U. 

These  lectures  are  published  at  the  request  of  medical  gentlemen  of  the  highest  standing,  m 
dlifcreiit  sections  of  our  country,  as  well  as  many  abroad,  who  are  anxious  to  have  Dr.  Sayre'» 
peculiar  views  and  extended  experience  in  this  specialty  given  to  the  profession  in  a  plain  au<J 
practical  manner.  The  book  contains  the  substance  of  his  course  of  lectures  delivered  at  BellO' 
Tue  Hospital  Medical  College,  as  well  as  many  import.ant  cases  from  his  note-book,  and  from  iha 
hospital  records.  He  has  also  added  a  number  of  cases  before  presented  by  him  to  the  profes- 
sion in  medical  journals,  or  at  the  different  medical  societies,  which  are  considered  worthy  of 
permanent  record. 

The  work  is  enriched  by  beautiful  and  excellent  illustrations,  engraved  from  original  draw- 
tngs  and  photographs  prepared  expressly  therefor.  The  author  having  enjoyed  exceptional  op- 
portunities for  the  study  and  treatment  of  these  diseases,  the  results  of  his  labors  cannot  fail  to 
be  of  inestimable  value  to  every  student  and  practitioner,  and  of  service  to  suffering  humanity. 

STEINER. 

Compendium   of  Children's   Diseases. 

A  Hand-booh  for  Practitioners  and  Students. 
By  Dr.  JOHANN  STEINER, 

Professor  of  the  Diseases  of  C3iildren  in  the  University  of  Prague,  and  Physician  to  the  FranclS' 
Josej)h  Hospital  for  Sick  Children. 

Translated  from  the  Second  German  Edition  by  Lawson  Tait,  P.  R.  C.  S., 

Surgeon  to  the  Birmingham  Hospital  for  TVomcn ;  Consulting  Surgeon  to  the  West  Bromwlclt 
Hospital;  Lecturer  on  Physiology  at  the  Midland  Institute. 

1  vol.,  8vo.    Cloth,  $3.50. 

TRANSLATOR'S     PREFACE. 

Dr.  Stoiner's  book  has  met  -nith  such  m.nrked  success  in  Germany  that  a  second  edition  hn» 
already  .ippeared.  a  circumstance  which  has  delayed  the  appearance  of  its  English  form.  In  ordef 
that  I  might  be  able  to  give  his  .additions  and  corrections. 

In  Germany  the  use  of  the  metric  system  has  not  yet  entirely  superseded  the  local  measures; 
but  it  is  rapidly  doing  so,  as  In  England.  I  have,  therefore,  rendered  all  thermometric  observa- 
tions in  the  Centigrade  scale,  and  all  measurements  in  centi-  and  millimetres. 

I  have  added  as  an  Appendix  the  '•  Kules  for  Management  of  Infants"  which  have  been  issnetl 
by  the  staff  of  the  Birmingham  Sick  Children's  Hosi'Sital,  because  I  think  that  they  have  sot  ao 
example  by  freely  distributing  these  rules  among  the  poor  for  which  they  ciunot  bo  sulDciently 
commended,  and  which  it  would  be  wise  for  other  sick  children's  hospitals  to  follow. 

I  have  also  added  a  few  notes,  chiedy,  of  course,  relating  to  the  surgical  ailmtuts  of  children. 

BEKMiNQnAM,  October,  1874.  LAWSON  TAIT. 


26  D.  Appleton  tb  Co.^s  Medical  Publications. 

STKOUD. 
The  Physical  Cause  of  the  Death  of 

Christ,  and  its  Melations  to  the  Principles  and  Practice 
of  Christianity. 

By  WILLIAM    STROUD,   M.  D. 
With  a  Letter  on  the  Subject,  by  Sir  James  "Y.  Simpson,  Bart.,  M.  D. 
1  vol.,  12mo.    422  pp.    Cloth,  $2.00. 
This  Important  and  remarkable  book  is,  Is  its  ovm  phce,  a  masterpiece,  and  will  be  considered 
M  a  standard  work  for  many  years  to  come. 

"The  principal  point  insisted  on  is,  that  the  death  of  Christ  was  caused  by  rupture  or  lacera- 
tion of  the  heart.  Sir  James  Y.  Simpson,  who  had  read  the  author's  treatise  and  various  com- 
ments on  it,  expressed  himself  very  positively  in  favor  of  the  views  maintained  by  Dr.  Stroud." 
— Psychological  Journal. 

SIMPSON. 
The  Posthumous  Works  of  Sir  James 

Young  Simpson,  Bart.,  M.  D.     In  Three  Volumes. 

Volume  I. — Selected  Obstetrical  and  Gjjncecological  Works  of  Sir  James  Y.  Simpson, 
Bart.,  M.  D.,  D.  C.  L..  late  Professor  of  Midwifery  in  the  University  of  Edinburgh.  Contain- 
ing the  substance  of  his  Lectures  on  Midwifery.  Edited  by  .r.  Watt  Black,  A.  M»  M.  D., 
Member  of  the  Royal  College  of  Physicians,  London ;  Physician- Accoucheur  to  Cliaring 
Cross  Hospital,  London :  and  Lecturer  on  Midwifery  and  Diseases  of  Women  and  Children 
in  the  Hospital  School  of  Medicine. 

1  vol.,  8vo.    862  pp.    Cloth,  $3.00. 

This  volume  contains  all  the  more  important  contributions  of  Sir  .Tames  T.  Simpson  to  the 
Btudy  of  obstetrics  and  diseases  of  Women,  with  the  exception  of  his  clinical  lectures  on  the  latter 
subject,  which  will  shortly  appear  in  a  separate  volume.  This  first  volume  contains  many  of  the 
papers  reprinted  from  his  Obstetric  Memoirs  and  Contributions,  and  also  liis  Lecture  Notes,  now 
published  for  the  first  time,  containing  the  substance  of  the  practical  part  of  his  course  of  mid- 
wifery. It  is  a  volume  of  great  interest  to  the  profession,  and  a  fitting  memorial  of  its  renowned 
and  talented  author. 

"To  many  of  our  readers,  doubtless,  the  chief  of  the  papers  It  contains  are  familiar.  To 
others,  although  pmbably  they  may  be  aware  that  Sir  James  Simpson  has  \vritten  on  the  sub- 
jects, the  papers  themselves  will  bo  new  and  fresh.  To  the  first  class  we  would  recommend  thl« 
edition  of  Sir  James  Simpson's  works,  as  a  valuable  volume  of  reference ;  to  the  latter,  as  a  colleo- 
tion  of  the  works  of  a  great  master  and  improver  of  his  art,  the  study  of  which  cannot  fail  to  malu 
them  better  prepared  to  meet  and  overcome  its  difficulties." — MediccU  Times  and  Gazette. 

Volume  II. — Anaesthesia,  Htspilallsm,  etc.     Edited  by  Sir  Waltkr  Simpson,  Bart. 
1  vol.,  8vo.    560  pp.    Cloth,  $3.00. 
"  We  say  of  this,  as  of  the  first  volume,  that  it  should  find  a  place  on  the  table  of  every  prao- 
iitioner ;  for,  though  it  is  patchwork,  each  piece  may  be  picked  out  and  studied  with  pleasure  and 
pro  at" — The  Lancet  (London). 

Volume  III. —  The  Diseases  of  Women.  Edited  by  Alex.  Simpson,  M.  D.,  Professor 
of  Midwifery  in  the  University  of  Edinburgh. 

1  vol.,  8vo.    Cloth,  $3.00. 
One  of  the  best  works  on  the  subject  extant.    Of  inestimable  value  to  every  physician. 

SWETT. 
A  Treatise  on  the  Diseases  of  the  Chest. 

Being  a  Course  of  Lectures  delivered  at  the  New  York 
Hospital. 

By  JOHN  A.  SWETT,  M.  D., 

Professor  of  the  Institutes  and  Practice  of  Medicine  in  the  New  York  University ;  Physician  to 
the  New  York  Hospital ;  Member  of  the  New  York  Pathological  Society. 

1  vol.,  8vo.    687  pp.    $3.50. 

Embodied  in  thia  Tolome  of  lectures  is  the  experience  of  ten  years  in  hospital  and  i»lTata 
Oractlce. 


D.  Appleton  db  Cc's  Medical  Publications.  27 

SAYKE. 
A  Practical  Manual  on  the  Treatment 

of  Cluh-Foot. 

By  lewis  a.  SAYRE,  M.  D., 

Professor  of  Orthopedic  Surgery  in  Bellevue  Hospital  Medical  College;  Surgeon  to  Bellevne  and 

Charity  Hospitals,  etc. 

1  vol ,  12ino.    New  and  Enlarged  Edition.    Cloth,  $1.00. 

"  The  object  of  this  work  is  to  convey,  in  as  concise  a  manner  as  possible,  all  the  practical  In- 
formation and  instruction  necessary  to  enable  the  general  practitioner  to  apply  that  plan  of  treat- 
ment which  has  been  so  successful  in  my  own  hands." — Preface. 

"The  book  will  very  well  satisfy  the  wants  of  the  majority  of  general  practitioners,  for  whoM 
use,  as  stated,  it  is  intended." — Isiew  York  Medical  JouinaL 

SMITH. 

On  Foods. 

Br  EDWARD  SMITH,  M.  D.,  LL.  B.,  F.  R.  S., 

Fellow  of  the  Eoyal  College  of  Physicians  of  London,  etc.,  etc. 
1  vol.,  12mo.    Cloth.    Price,  $1.75. 

"  Since  the  issue  of  the  author's  work  on  "  Practical  Dietary,"  he  has  felt  the  want  of  another, 
•which  would  embrace  all  the  generally-known  and  less-known"foods,  and  contain  the  latest  scien- 
tific knowledge  respecting  them.  The  present  volume  is  intended  to  meet  tbis  want,  and  will  be 
found  useful  for  reference,  to  bi'th  scientific  and  general  readers.  The  author  extends  the  ordl- 
narjf  view  of  foods,  and  includes  water  and  air,  since  they  are  important  both  in  Uielr  food  and 
sanitary  aspects. 

SCHKOEDER 

A     Manual    of    Midwifery.      including  the  Pa- 
thology of  Pregnancy  and  the  Puerperal  State. 

By  Dr.  KARL  SCHROEDER, 
Professor  of  Midwifery  and  Director  of  the  Lying-in  Institution  in  the  University  of  Erlangen. 

TEANSLATED  FKOM  TUE  THIRD  GEBMAN  EDITION 

By  CHARLES  H.  CARTER,  B.  A.,  M.  D.,  B.  S.  London, 

Member  of  the  Eoyal  College  of  Physicians,  London,  and  Physician  Accoucheur  to  St  George'i, 

Hanover  Square,  Dispensary. 

With  Twenty-six  Engravings  on  Wood.  1  vol.,  8vo.  Cloth. 
"The  translator  feels  that  no  apology  is  needed  in  ofi'ering  to  the  profession  a  translation  of 
Schroeder's  Manual  of  Midwifei-y.  The  work  is  well  known  in  Germany  and  extensively  used  aa 
a  text-book;  it  has  already  reached  a  third  edition  within  the  short  space  of  two  years,  and  it  ia 
hoped  that  the  present  translation  will  meet  the  want,  long  felt  in  this  countrj',  of  a  manual  of 
midwifeiy  embracing  the  latest  scientific  researches  on  the  subject. 

TILT. 

A  Hand-Book  of  Uterine   Therapeu- 
tics and  of  Diseases  of  Women. 

By  EDWARD   JOHN  TILT,  M.  D., 
Member  of  the  Eoyal  College  of  Physicians ;  Consulting  Physician  to  the  Farringdon  General 
Dispensary;  Fellow  of  the  EoyalMedical  and  Chirurgical  Society,  and  of  several  British  and 
foreign  societies. 

1  vol.,  8vo.    345  pp.    Cloth,  $3.50. 

Second  American  edition,  thoroughly  revised  and  amended: 

"  In  giving  the  result  of  his  labors  to  the  profession  the  author  has  done  a  great  work.  Our 
readers  will  find  its  pages  very  interesting,  and.  at  the  end  ol  their  task,  will  feel  gniteful  to  the 
author  for  many  very  valuable  suggestions  as  to  the  treatment  of  uterine  diseases." — The  Lancet. 

"Dr.  Tilt's  '  Hand-Book  of  Uterine  Therapeutics '  supplies  a  want  which  has  often  been  felt. 
.  .  It  may,  therefore,  be  read  not  only  with  pleasure  and  Instruction,  but  will  also  be  fonnd 
TeiT  useful  as  a  book  of  reference." — The  Medical  Mirror. 

"  Second  to  none  on  the  therapeutics  of  uterine  disease." — Journal  of  Obstetric*. 


S8  D.  Appleton  d?   Co.'s  Medical  Publications. 

VAN   BUREN  AND   KEYES. 
A   Practical  Treatise  on  the   Surgical 

Diseases  of  the  Genito- Urinary  Organs^  including  Syphi- 
lis. Designed  as  a  Manual  for  Students  and  Practition- 
ers.     With  JEngravings  and  Cases. 

By  W.   H.   van   BUKEN,  A.  M.,  M.  D., 

Professor  of  Priuciples  of  Surgery,  with  Diseases  of  the  (icnito-Uritiary  System  and  Clinical 
Surgery,  in  Bellevue  Hospital  Medical  College;  Consulting  Sui-geou  "to  Ibc  ^ew  York  Hos- 
pital, the  Charity  Hospital,  etc. ;  and 

E.  L.  KEYES,  A.  M.,  Vi.  D., 

Professor  of  Dermatol' iry  In  Bellevue  Hospital  Medical  Collr;:i^;  PuvfTCon  to  thi^  Charity  Hos- 
pital, Venereal  ]>i'  ses;  Consulting  De'-matologisl  to  the  liuieuu  of  (Jut-Door  liclict,"  Belle- 
vue Hospital,  etc 

1  vol.,  8vo.    ClotH,  $6.00;  Sheep,  $6.00. 

This  work  is  really  a  coi.-jieii ilium  of,  and  a  book  ol"  ruierence  to,  all  modem 
works  treating  in  any  way  of  the  Kuigical  diseases  of  the  genito-uriuaiy  organs.  At 
the  same  time,  no  other  single  book  contains  so  laige  an  array  of  original  facts  con- 
cerning the  class  of  diseases  with  which  it  deals.  These  facts  are  largely  drawn 
from  the  extensive  and  varied  experience  of  the  authors. 

Many  important  branches  of  genito-urinary  diseases,  as  the  cutaneous  maladiea 
of  the  penis  and  scrotiun,  receive  a  thorough  and  exhaustive  treatment  that  the  pro- 
fessional reader  will  search  for  elsewhere  in  vain. 

The  work  is  elegantly  and  profusely  illustrated,  and  enriched  by  fiftj'-five 
original  cases,  settiug  forth  obscure  and  difficult  points  in  diagnosis  and  treatment. 

"The  first  part  is  devoted  to  the  Surgical  Diseases  of  the  Genito-TJrinary  Organs;  and  part 
fiecond  treats  of  Chancroid  and  Sj'philis.  The  authors  'appear  to  have  succeeded  admirably  in 
giving  to  the  world  an  exhaustive  .and  reliable  tieatise  on  this  important  class  of  diseases.' " — 
Morlhwestern  Medical  and  Surgical  Jonrnal. 

'■It  is  a  most  complete  digest  of  what  has  long  been  known,  and  of  what  has  been  more  re- 
cently discovered,  in  the  field  of  syi>hilitic  and  genito-urinary  disorders.  It  is  jierhaps  not  an 
£.\aggeration  to  say  that  no  single  worli  ujion  the  same  subject  has  jet  appeared,  in  this  or  any 
foreifin  language,  wliich  is  superior  to  it."—  (Jbicago  Medical  Examiner. 

"  The  commanding  rej)Utatiou  of  Dr.  Van  Buren  in  this  specialty  aud  of  the  great  school  .ind 
lios])ital  froui  whicli  lie  has  drawn  his  clinical  materials,  together  with  the  general  interest  which 
attaches  to  the  subject-matter  itself,  will,  we  trust,  lead  very  many  of  those  for  whom  it  is  our 
flllice  to  cater,  to  possess  themselves  at  once  of  the  volume  and  form  their  own  opinions  of  its 
ixiL-rii.''^— Atlanta  Medical  and  Surgical  Journal. 

Lectures  upon  Diseases  of  the  Rectum. 

Delivered  at  the  Pellevue  Hospital  Medical  College. 
Session  o/1869-'70. 

By  W.  H.  van  buren,  M.  D., 

1  vol.,  12mo.     164  pages.     Cloth,  $1.50. 

"  It  seems  hardly  necessary  to  more  than  mention  the  name  of  the  author  of  this  admirable 
little  volume  in  order  to  insuio  the  character  of  his  bool^.  No  one  in  this  country  has  enjuved 
greater  advantages,  and  had  a  more  extensive  field  of  observation  in  this  specialty,  than  Dr. 
Van  Buren.  aud  no  one  has  i>aid  the  same  amount  of  attention  to  the  subject.  .  .  .  Here  is  the 
«xpei-ience  of  years  summed  up  aud  given  to  the  prolessional  world  in  a  plain  and  practical  uiaa- 
ner." — Psychuk/gicul  Journal. 


D.  Appleton  &   Co.^s  Medical  Publications.  -^c) 


VOQEL. 
A  Practical  Treatise  on  the  Diseases 

of  Children.  Second  American  from  the  Fourth 
German  Edition.  Illustrated  ly  Six  Lithographic 
Plates. 

By  ALFRED  VOGEL,  M.  D., 

Professor  of  Clinical  Medicine  in  the  University  of  Dorj)at,  SomIk. 
TRANSLATED  AND  EDITED  BY 

n .   R  A  r  n  A  E  L ,   m  .  d  . , 

Lit0  Boom  Svirgeon  to  Bellevuo  Ilosi.ital ;  Physician  to  the  Eastern  Dispensary  for  ihe  Dieeuoe 

of  Children,  etc.,  etc. 

1  vol.,  8vo.     611  pp.     Cloth,  $4.50. 

The  work  is  well  up  to  the  present  state  of  pathological  knowledge ; 
complete  without  unnecessary  prolixity;  its  symptomatology  accurate, 
evidently  the  result  of  careful  observation  of  a  competent  and  experi- 
enced clinical  practitioner.  The  diagnosis  and  differential  relations  of 
diseases  to  each  otlier  are  accurately  described,  and  the  therapeutics 
judicious  and  discriminating.  All  polypharmacy  is  discarded,  and  only 
the  remedies  which  appeared  useful  to  the  author  commended. 

It  contains  much  that  must  gain  for  it  the  merited  praise  of  all  im- 
partial judges,  and  prove  it  to  bo  an  invaluable  text-book  for  the  stu- 
dent and  practitioner,  and  a  safe  and  useful  guide  in  the  difficult  but  all- 
important  department  of  Padiatrica. 

"  Rapidly  passing  to  a  fourth  edition  in  Germany,  and  translated  into  three 
other  languages,  Anaerica  now  has  the  credit  of  presenting  the  first  English  ver- 
eion  of  a  book  whicli  must  take  a  prominent,  if  not  the  leading,  position  among 
works  devoted  to  this  class  of  disease." — N.  Y.  Medical  Journal. 

"  The  profession  of  this  country  are  under  many  obligations  to  Dr.  Raphael 
for  bringing,  as  he  has  dona,  this  truly  valuable  work  to  their  notice." — Medical 
iUcord. 

"The  translator  has  been  more  than  ordinarily  successful,  and  bis  labors 
have  resulted  in  what,  in  every  sense,  is  a  valuable  contribution  to  medicii 
ecience." — Psychological  Journal. 

"We  do  not  know  of  a  compact  text-book  on  the  diseases  of  children  more 
complete,  more  comprehensive,  more  replete  with  practical  remarks  and  scientific 
facts,  more  in  keeping  with  the  development  of  modem  medicine,  and  more 
worthy  of  the  attention  of  the  profession,  than  that  which  has  been  the  subjed 
of  our  remarks." — Join-nal  of  Olstetrict. 


30  D.  Appleton  <&   Co.^s  Medical  Publications. 

WALTON. 

The  Mineral  Springs  of  the  United 

States  and  Canada,  with  Analyses  and  Notes  on  the 
Prominent  Spas  of  Europe,  and  a  List  of  Sea-side 
Resorts.    An  enlarged  and  revised  edition. 

By  GEORGE  E.  WALTON,  M.D., 

Lecturer  on  Materia  Medica  in  the  Miami  Medical  College,  Cincinnati, 

Second  Edition,  revised  and  enlarged.  1  vol.,  12mo.  390  pp.,  witli  Maps.  $2.00. 

The  author  has  given  the  analyses  of  all  the  springs  in  this  country  and 
those  of  the  principal  European  spas,  reduced  to  a  uniform  standard  of 
one  wine-pint,  so  that  they  may  readily  be  compared.  He  has  arranged 
the  springs  of  America  and  Europe  in  seven  distinct  classes,  and  de- 
scribed the  diseases  to  which  mineral  waters  are  adapted,  with  refer- 
ences to  the  class  of  waters  applicable  to  the  treatment,  and  the  pecul- 
iar characteristics  of  each  spring  as  near  as  known  are  given — also,  the 
location,  mode  of  access,  and  post-office  address  of  every  spring  are  men- 
tioned. In  addition,  he  has  described  the  various  kinds  of  baths  and 
the  appropriate  use  of  them  in  the  treatment  of  disease. 

EXTKACTS  FROM  OPINIONS  OF  THE  PRESS. 

"...  Precise  and  comprehensive,  presenting  not  only  reliable  analyses  of 
the  waters,  but  tVieir  therapeutic  value,  so  that  physicians  can  hereafter  advise 
their  use  as  intelligently  and  beneficially  as  they  can  other  valuable  alterative 
iigents." — Sanitarian. 

"...  Will  tend  to  enlighten  both  the  profession  and  the  people  on  this 
question." — N.  Y.  Medical  Journal. 

"...  Contains  in  brief  space  a  vast  amount  of  important  and  interesting 
matter,  well  arranged  and  well  presented.  Nearly  every  physician  needs  just 
Buch  a  volume  " — Richmond  and  Louisville  Medical  Journal. 

"...  Fills  this  necessity  in  a  scientific  and  pleasing  manner,  and  can  be  read 
with  advantage  by  the  physician  as  well  as  layman." — American  Jour,  of  Obstetrics. 

TJsrviBBiTT  or  VnonnA,  June  9,  1878. 

Gentlkmsk  :  I  have  received  by  mail  a  copy  of  Dr.  Walton's  work  on  the 
Mineral  Springs  of  the  United  States  and  Canada.  Be  pleased  to  accept  my 
thanks  for  a  work  which  I  have  been  eagerly  looking  for  ever  since  I  had  the 
pleasure  of  meeting  the  author  in  the  summer  of  1871.  He  satisfied  me  that 
he  was  well  qualified  to  write  a  reliable  work  on  this  subject,  and  I  doubt  not 
he  has  met  my  expectations.  Such  a  work  was  greatly  needed,  and,  if  ofiered 
for  sale  at  the  principal  mineral  springs  of  the  country,  will,  I  believe,  com- 
mand a  ready  sale.     Very  respectfully  yours, 

J.  L.  Cabell,  M.  D. 


D.  Appleton  <&   Co.^s  Medical  Publications.  31 

WELLS. 
Diseases  of  the  Ovaries  ;  Their  DiagnoeU 

and  Treatment. 

By  T.  SPENCER  WELLS, 

fellow  and  Member  of  Council  of  the  Eoyal  College  of  Surgeons  of  England  ;  nonomry  Fello-w 
of  the  King  and  Queen's  College  of  Physicians  in  Ireland;  Surgeon  in  Ordinary  to  the 
Queen'B  Household;  Surgeon  to  the  Samaritan  Hospital  for  Women;  Member  or  the  Im- 
perial Society  of  Surgery  of  Parts,  of  the  Medical  Society  of  Paris,  and  of  the  Medical  Soci- 
ety of  Sweden;  Honorary  Member  of  the  Royal  Society  of  Medical  and  Natural  Science 
of  Brussels,  and  of  the  Medical  Societies  of  Pesth  and  Helslngfors ;  Honorary  Fellow  of 
the  Obstetrical  Societies  of  Berlin  and  Leipzig. 

1  vol,  8vo.    478  pp.    Illustrated.    Cloth,  Price,  $4.50. 

In  1865  the  author  issued  a  volume  containing  reports  of  one  hundred  and 
fourteen  cases  of  Ovariotomy,  which  was  little  more  than  a  simple  record  of 
facts.  The  book  was  soon  out  of  print,  and,  though  repeatedly  asked  for  a 
new  edition,  the  author  was  unable  to  do  more  than  prepare  papers  for  the 
Royal  Medical  and  Chirurgical  Society,  as  series  after  series  of  a  hundred  casea 
accumulated.  On  the  completion  of  five  hundred  cases  he  embodied  the  resulta 
in  the  present  volume,  an  entirely  new  work,  for  the  student  and  practitioner, 
and  trusts  it  may  prove  acceptable  to  them  and  useful  to  suffering  women. 

"  Arrangements  have  been  made  for  the  publication  of  this  volume  in  Lon- 
don on  the  day  of  its  publication  in  New  York."  French  and  German  transla- 
tions are  already  in  press. 

WAaiSTER. 
A    Hand  -  book   of  Chemical    Tech- 

nology. 

By  RUDOLPH  WAGNER,  Ph.  D., 

Professor  of  Chemical  Technology  at  the  University  of  Wurtzburg. 

Translated  and  edited,  from  the  eighth  German  edition,  with  exteajislve 

additions, 

By  WILLIAM  CROOKES,  F.  R.  S. 

With  336  Illustrations.    1  vol.,  8vo.    781  pages.    Cloth,  $5.00. 

Under  the  head  of  Metallurgic  Chemistry,  the  latest  methods  of  preparing  Iron,  Cobalt, 
Nickel  Copner.  Copper  Salts,  Lead  and  Tin.  and  th«ir  Salts,  BismntK  Zinc,  Zinc  SalU,  Cad- 
mium, Antimony,  Arsenic,  Mercury.  Platinum,  Silver.  Gold,  Manpanates,  Ainminnm.  and 
Magneslnm,  are  "described.  The  various  applications  of  the  Voltaic  Current  to  Electro- M«ital- 
lurgT  follnw  under  this  division.  The  preparation  of  Potash  and  Soda  SalU*.  the  mannfactur* 
of  Sulphuric  Acid,  and  the  recovery  of  Sulphur  from  Soda  Waste,  of  course  occupy  prominnnt 
places  in  the  consideration  of  chemical  man\if:wture3.  It  Is  dillicult  to  over-estiinnte  the  mer- 
cantile value  of  Mond's  process,  as  well  a.s  the  many  new  and  impiirtant  applications  of  Bisul- 
phide of  Carbon.  The  manufacture  of  Soap  will  be'founil  to  include  much  detail.  The  Tech- 
noloerv  of  Olaes,  Stone-ware,  Limes,  and  Mortars,  will  present  mnch  of  Interest  to  the  Builder 
and  Engineer.  The  Technology  of  Vegetable  Fibres  has  been  considered  to  include  the  pren- 
aration  of  Flax,  Hemp,  Cotton,  as  well  as  Paper-making;  while  the  applicati.ins  of  V  egetabl* 
Products  will  be  found  to  include  Sugar-boiling.  Wine  and  Beer  Brewing,  the  Distillation  of 
Bpirita.  the  Baking  of  Bread,  the  Preparation  of  Vinegar,  the  Preservation  of  Wo<>d,  etc. 

Dr.  Wagner  gives  much  tnforiuatifin  in  reference  to  the  production  of  Potash  from  Sugar 
realdnes.  The  use  of  Baryta  Salts  is  also  flilly  described,  as  well  an  the  preparation  of  Sugar 
from  Reet-ronta,  Tanning,  the  Preservation  of  Meat,  Milk.  etc„  the  Preparation  of  Pho8ph»- 
ms  and  Animal  Charco.iL  are  con.sldered  as  belonging  to  the  Tecl^nology  of  Animal  Product*. 
The  Preparation  of  Materials  for  Dyeing  has  necessarily  required  much  space ;  while  the  flnW 
Mctlon*  of  the  book  hare  been  devoted  to  the  Technology  of  Heating  and  lUamlnatloa. 


THE  NEW  YORK  MEDICAL  JOURNAL 

JAMES  B.  EVXTEB,  M.  D.,  Editor. 
Published  Monthly,   Volumes  begin  in  January  and  July. 


"Among  the  numerous  records  of  Medicine  and  tin-  collateral  sciences  published  In  America, 
the  above  Journal  occupies  a  high  position,  and  deservedly  so." — The  Lancet  (London). 

"One  tf  the  best  medicil  journals,  by-the-by,  published  on  the  American  Continent."— Zon- 
don  Medical  'J  imes  and  Gazette. 

"A  very  high-class  journal." — London  Medical  Mirror. 

"The  editor  and  the  contribiitors  r.mk  among  our  most  distinguished  medical  men,  and  each 
nnrabcr  contains  matter  that  does  honor  to  American  medical  literature." — Boston  Journal  of 
Chemistry. 

"Full  of  valuable  originnl  papers,  abounding  in  scientific  .ability." — Chicago  Medical  Timet 

"  We  know  no  other  jicriodical  that  we  would  rather  present  as  a  specimen  of  American  sklL 
tnd  intelligence  than  the  New  York  Medical  Jouu.nal." — Franklin  lieposilory. 

"  The  New  Tork  Medical  Jouiinai,,  edited  by  Dr.  James  B.  Hunter,  is  one  of  the  sterling 
periodicals  of  this  country.  The  present  editor  has  gre.itly  improved  the  work,  and  evinces  a 
marked  aptitude  for  the  responsible  duties  so  well  discharjred.  The  contents  of  this  journal  are 
always  interesting  and  instructive ;  its  original  matter  is  often  classic  in  value,  and  the  selected 
articles  are  excellent  exponents  of  the  progress  and  truth  of  medical  science." — liichmond  and 
Louisville  Medical  Journal, 

Terms,  $4.00  per  Annum  5  or  40  Cents  per  Number. 

^ — ^ — .^ 

THE  POPULAR  SCIENCE  MONTHLY. 

Conducted  hy  Prof.  E.  L.  YOUMAjYS. 

Each  Number  contains  128  pages,  with  numerous  Descriptive  and 
Attractive  Illustrations. 

Published  Monthly.   Volumes  begin  in  May  and  November. 

Terms,  $5  per  Auuuiu,  or  Fifty  Cents  per  Number 


Tire  PoPTr-AS  Science  Mokthlt  was  started  to  promote  the  diffusion  of  valuable  scientlfli 
knowledge,  ia  a  readable  and  attractive  form,  among  nil  classes  of  the  community,  and  has  thus 
far  met  a W.int  supjilied  by  no  other  periodical  in  the  United  States. 

The  great  feature  of  the  magazine  isi,  that  its  contents  are  not  what  science  ^cas  ten  or  more 
years  since,  but  what  it  is  to-day,  fresh  from  the  study,  the  laborntniy,  and  the  experiment: 
clothed  in  the  language  of  the  authors,  inventors,  and  scientists  themselve.">,  which  coujjirise  the 
leading  minds  of  Kngland.  Franco,  ticrmany.  and  the  United  States.  Among  popular  articles, 
covering  the  whole  range  of  Natitkal  Science,  we  have  the  latest  thouj;hts  and  words  of  Her- 
bert Spencer,  and  Professors  Huxley,  Tyndall.  and  li.  A.  I'n'Ctor.  Since  the  start,  it  has  jiroved 
ft  gratifying  success  to  every  friend  of  scientillc  progress  and  universal  education;  and  those  wlio 
believed  th.at  science  could  not  be  made  any  thing  but  dry  study,  are  disappointed. 

The  press  all  over  the  land  is  warmly  commending  it.  We  subjoin  a  few  encomiiims  fl-om 
those  recently  given: 

"  A  journal  which  promises  to  be  of  eminent  value  to  the  cause  of  popular  education  in  thla 
country." — Sent  York  'J'ribune. 

"lt"is,  beyimd  coiii[iarison,  the  best  attempt  at  journalism  of  the  kind  ever  made  in  this  coun- 
try."— Home  Journal. 

"Tlie  initial  iiumhcris  admirably  con.stitutod."— ^r^rtinf?  Mall. 

*'  In  our  opinion,  the  right  idea  has  been  happily  hit  in  the  plan  of  this  new  monthly." — Buffalo 
Courier. 

"  J  ust  the  publication  needed  at  the  present  day." — Montreal  Gazette. 


Payment,  in  all  cases,  must  be  made  in  advance, 

Eemittances  should  be  made  by  postal  money-order  or  check  to  the  rubhsbers, 

JD.   jLJPJPLJ^TOir  ^  CO., 

S40  &  551  Broadtvaij,  Xetv  Tork, 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  s£aiii|>ctl  below. 


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